Cardiac complications as initial manifestation of pheochromocytoma: frequency, outcome, and predictors

OBJECTIVE

To examine the frequency, outcome, and clinical predictors of cardiac complications as the initial manifestation of pheochromocytoma.

METHODS

The medical records of all 76 patients with pheochromocytoma or functional paraganglioma treated at Cedars-Sinai Medical Center, Los Angeles, California, from 1995 to 2011 were reviewed. The patients initially presenting with cardiac complications were identified, and their clinical, laboratory, and imaging characteristics were compared with those of the patients presenting with other complaints, especially hypertension and adrenal mass.

RESULTS

Of the 76 patients, 9 (12%) presented with the following: 2 with acute heart failure, 1 with left ventricular thrombus, 3 with myocardial infarction, and 3 with severe arrhythmia. Failure to diagnose pheochromocytoma resulted in unnecessary invasive interventions in 2 patients. Recovery of cardiac function was excellent after resection of the tumor in all patients. In comparison with the 67 patients presenting with other complaints, the 9 with cardiac complications had similar demographics and cardiac risk factors but harbored larger tumors (6.7 ± 0.8 cm versus 4.4 ± 0.3 cm; P = .015) and exhibited higher biochemical marker levels (23.9 ± 9.0-fold versus 11.3 ± 2.4-fold; P = .082), longer corrected QT interval (473 ± 8 ms versus 443 ± 6 ms; P = .015), and lower ejection fraction (43% ± 8% versus 66% ± 2%; P = .002).

CONCLUSION

In this study, 12% of patients with pheochromocytoma initially presented with cardiac complications. Patients with large tumors and high levels of biochemical markers were more likely to develop cardiac injury. Our results confirm that the presence of pheochromocytoma should be ruled out in patients with cardiac diseases and features suggesting pheochromocytoma so that unnecessary interventions can be avoided and cardiac recovery can be achieved.

A simple algorithm for drain management after pancreaticoduodenectomy

Pancreatic fistula (PF) continues to be the Achilles' heel of pancreaticoduodenectomy (PD) with both morbidity and mortality linked to its occurrence. The optimal drain management strategy after PD remains unclear. We evaluated drain amylase (DA) levels on postoperative Day (POD) 0 to 5 in 76 consecutive patients undergoing PD to determine the patterns associated with PF. Of these 76 patients, eight patients (11%) developed Grade A, B, or C PF by International Study Group of Pancreatic Fistula criteria. POD 1 DA levels correlated closely with PF rates when high (greater than 5000 U/L, 100% PF rate) and low (less than 100 U/L, 2% PF rate). In patients with intermediate POD 1 DA (100 to 5000 U/L), 42 and 74 per cent had low DA levels on POD 3 and 5, respectively, and the PF rate was four of 31 (13%). Overall, the temporal pattern of decreasing DA levels after PD correlates closely with the risk of PF, and only two patients (5%) developed PF after early DA levels had normalized. Based on these data, we propose an algorithm of monitoring DA daily with drain removal when the level is less than 100 U/L. In our patient group drain removal would have occurred on a mean of 1.8 days and median 1 day after surgery.

Novel syndrome of four-limb proximal fragility fractures associated with HIV infection, cholestatic liver failure, and histiocytic infiltration of bone marrow

We report a syndrome of four-limb proximal fragility fractures associated with HIV infection, cholestatic liver failure, and histiocytic infiltration of bone marrow in a 40-year-old African American man. The patient presented with multiple fractures in the proximal humeri and femurs without osteopenia in the vertebrae. His right humerus appeared normal on chest X-ray film 3 years before presentation when he was first diagnosed with HIV infection and abnormal liver functions. At presentation, the patient had vitamin D deficiency, hypogonadism, and low IGF- 1 levels, but did not have hyperparathyroidism. Bone biopsy showed diffuse foamy histiocytic infiltration of bone marrow at all fracture sites without evidence of infectious or neoplastic processes. Exhaustive search did not identify any similar cases in the English literature. Our case likely represents a novel syndrome, the etiology of which is probably multifactorial and includes HIV infection, cholestatic liver failure, immobility, and endocrine abnormalities. The case further calls for the need for monitoring of bone health in patients with HIV infection or liver disease.

Video-microscopy for use in microsurgical aspects of complex hepatobiliary and pancreatic surgery: a preliminary report

BACKGROUND

The use of loupe magnification during complex hepatobiliary and pancreatic (HBP) surgery has become routine. Unfortunately, loupe magnification has several disadvantages including limited magnification, a fixed field and non-variable magnification parameters. The aim of this report is to describe a simple system of video-microscopy for use in open surgery as an alternative to loupe magnification.

METHODS

In video-microscopy, the operative field is displayed on a TV monitor using a high-definition (HD) camera with a special optic mounted on an adjustable mechanical arm. The set-up and application of this system are described and illustrated using examples drawn from pancreaticoduodenectomy, bile duct repair and liver transplantation.

RESULTS

This system is easy to use and can provide variable magnification of ×4-12 at a camera distance of 25-35 cm from the operative field and a depth of field of 15 mm. This system allows the surgeon and assistant to work from a HD TV screen during critical phases of microsurgery.

CONCLUSIONS

The system described here provides better magnification than loupe lenses and thus may be beneficial during complex HPB procedures. Other benefits of this system include the fact that its use decreases neck strain and postural fatigue in the surgeon and it can be used as a tool for documentation and teaching.

Recurrent hepatocellular carcinoma after liver transplant: identifying the high-risk patient

BACKGROUND

Recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT) is rarely curable. However, in view of the advent of new treatments, it is critical that patients at high risk for recurrence are identified.

METHODS

Patients undergoing LT for HCC at a single centre between 2002 and 2010 were reviewed and data on clinical parameters and explant pathology were analysed to determine factors associated with HCC recurrence. All necrotic and viable tumour nodules were included in explant staging. All patients underwent LT according to the United Network for Organ Sharing (UNOS) Model for End-stage Liver Disease (MELD) tumour exception policies.

RESULTS

Liver transplantation was performed in 122 patients with HCC during this period. Rates of recurrence-free survival in the entire cohort at 1 year and 3 years were 95% and 89%, respectively. Thirteen patients developed HCC recurrence at a median of 14 months post-LT. In univariate analysis the factors associated with HCC recurrence were bilobar tumours, vascular invasion, and stage exceeding either Milan or University of California San Francisco (UCSF) Criteria. Multivariate analysis showed pathology outside UCSF Criteria was the major predictor of recurrence; when pathology outside UCSF Criteria was found in combination with vascular invasion, the predicted 3-year recurrence-free survival was only 26%.

CONCLUSIONS

Explant pathology can be used to predict the risk for recurrent HCC after LT, which may allow for improved adjuvant and management strategies.

Pancreatic neuroendocrine tumors in glucagon receptor-deficient mice

Inhibition of glucagon signaling causes hyperglucagonemia and pancreatic α cell hyperplasia in mice. We have recently demonstrated that a patient with an inactivating glucagon receptor mutation (P86S) also exhibits hyperglucagonemia and pancreatic α cell hyperplasia but further develops pancreatic neuroendocrine tumors (PNETs). To test the hypothesis that defective glucagon signaling causes PNETs, we studied the pancreata of mice deficient in glucagon receptor (Gcgr^−/−) from 2 to 12 months, using WT and heterozygous mice as controls. At 2–3 months, Gcgr^−/− mice exhibited normal islet morphology but the islets were mostly composed of α cells. At 5–7 months, dysplastic islets were evident in Gcgr^−/− mice but absent in WT or heterozygous controls. At 10–12 months, gross PNETs (≥1 mm) were detected in most Gcgr^−/− pancreata and micro-PNETs (<1 mm) were found in all (n = 14), whereas the islet morphology remained normal and no PNETs were found in any WT (n = 10) or heterozygous (n = 25) pancreata. Most PNETs in Gcgr^−/− mice were glucagonomas, but some were non-functioning. No tumors predominantly expressed insulin, pancreatic polypeptide, or somatostatin, although some harbored focal aggregates of tumor cells expressing one of those hormones. The PNETs in Gcgr^−/− mice were well differentiated and occasionally metastasized to the liver. Menin expression was aberrant in most dysplatic islets and PNETs. Vascular endothelial growth factor (VEGF) was overexpressed in PNET cells and its receptor Flk-1 was found in the abundant blood vessels or blood islands inside the tumors. We conclude that defective glucagon signaling causes PNETs in the Gcgr^−/− mice, which may be used as a model of human PNETs. Our results further suggest that completely inhibiting glucagon signaling may not be a safe approach to treat diabetes.

Current surgical management of infected pancreatic necrosis

Infected pancreatic necrosis (IPN) continues to be a challenging problem for the surgeon. We reviewed the experience on a hepatobiliary surgical service with patients who required operative intervention for IPN with emphasis on surgical approach, timing of surgery, and complications. Between 2002 and 2008, 21 patients underwent surgery for IPN. The initial surgical approach in these 21 patients included either direct pancreatic débridement (DPD, n=13) or transgastric débridement using cyst-gastrostomy (CG, n=8). Fifteen patients (71%) required only a single procedure, whereas three (14%) required two procedures and three (14%) required three procedures. The mean time from onset of pancreatitis to operation was 77 days. Patients requiring a single intervention had a longer interval from onset of pancreatitis to surgery compared with those requiring multiple interventions. When comparing CG and DPD groups, there was a longer interval from onset of pancreatitis to débridement, a lower chance of needing multiple débridements, and fewer pancreatic fistulae in the CG group. Overall survival was 95 per cent. Our results demonstrate that CG can be successfully used in select patients with IPN. Patients undergoing CG are less likely to require repeat surgical debridement and to develop pancreatic fistulae compared with patients undergoing DPD.

Current Surgical Management of Infected Pancreatic Necrosis

Infected pancreatic necrosis (IPN) continues to be a challenging problem for the surgeon. We reviewed the experience on a hepatobiliary surgical service with patients who required operative intervention for IPN with emphasis on surgical approach, timing of surgery, and complications. Between 2002 and 2008, 21 patients underwent surgery for IPN. The initial surgical approach in these 21 patients included either direct pancreatic debridement (DPD, n = 13) or transgastric debridement using cyst-gastrostomy (CG, n = 8). Fifteen patients (71%) required only a single procedure, whereas three (14%) required two procedures and three (14%) required three procedures. The mean time from onset of pancreatitis to operation was 77 days. Patients requiring a single intervention had a longer interval from onset of pancreatitis to surgery compared with those requiring multiple interventions. When comparing CG and DPD groups, there was a longer interval from onset of pancreatitis to debridement, a lower chance of needing multiple debridements, and fewer pancreatic fistulae in the CG group. Overall survival was 95 per cent. Our results demonstrate that CG can be successfully used in select patients with IPN. Patients undergoing CG are less likely to require repeat surgical debridement and to develop pancreatic fistulae compared with patients undergoing DPD.

Pancreatic Neuroendocrine Tumors: Presentation, Management, and Outcomes

Pancreatic neuroendocrine tumors (pNETs) are an uncommon pancreatic neoplasm. We reviewed the presentation, management, and outcome of patients with pNETs treated at a single center by a multidisciplinary approach between 2004 and 2008. Over this time period, 154 patients with carcinoid and neuroendocrine tumors were treated, which included 46 patients (30% of total) with pNETs. The most common presentations included abdominal pain (20 of 46 [43%]), systemic symptoms such as hypoglycemia (15 of 46 [33%]), and incidental mass (7 of 46 [15%]). Fourteen patients had functional tumors. At the time of diagnosis, 22 patients (48%) presented without metastases and 24 (52%) had metastatic disease. Median follow up for the entire group was 42 months. All patients with nonmetastatic pNET underwent pancreatic resection with 95 per cent postoperative survival. Overall survival in this group at 3 years was 86 per cent and disease-free survival was 81 per cent. In patients presenting with metastatic pNET, multiple treatment modalities were used, including liver resection or ablation (n = 15), hepatic chemoembolization (n = 17), pancreatic resection (n = 12), and systemic treatments (n = 7). Three-year survival was 70 per cent. Pancreatic resection results in greater than 80 per cent 3-year survival in nonmetastatic pNET. In patients presenting with metastatic pNET, excellent survival rates are also achievable using a multidisciplinary multimodal approach.

Pancreatic neuroendocrine tumors: presentation, management, and outcomes

Pancreatic neuroendocrine tumors (pNETs) are an uncommon pancreatic neoplasm. We reviewed the presentation, management, and outcome of patients with pNETs treated at a single center by a multidisciplinary approach between 2004 and 2008. Over this time period, 154 patients with carcinoid and neuroendocrine tumors were treated, which included 46 patients (30% of total) with pNETs. The most common presentations included abdominal pain (20 of 46 [43%]), systemic symptoms such as hypoglycemia (15 of 46 [33%]), and incidental mass (7 of 46 [15%]). Fourteen patients had functional tumors. At the time of diagnosis, 22 patients (48%) presented without metastases and 24 (52%) had metastatic disease. Median follow up for the entire group was 42 months. All patients with nonmetastatic pNET underwent pancreatic resection with 95 per cent postoperative survival. Overall survival in this group at 3 years was 86 per cent and disease-free survival was 81 per cent. In patients presenting with metastatic pNET, multiple treatment modalities were used, including liver resection or ablation (n = 15), hepatic chemoembolization (n = 17), pancreatic resection (n = 12), and systemic treatments (n = 7). Three-year survival was 70 per cent. Pancreatic resection results in greater than 80 per cent 3-year survival in nonmetastatic pNET. In patients presenting with metastatic pNET, excellent survival rates are also achievable using a multidisciplinary multimodal approach.

Choledocho-choledochostomy in deceased donor liver transplantation

Biliary complications following deceased donor liver transplantation occur with an incidence of approximately 5-10%. The most common type of biliary reconstruction in whole-organ deceased donor liver transplantation remains the choledocho-choledochostomy, which creates an anastomosis between the donor and recipient common bile ducts or common hepatic ducts. Key elements in performing a successful choledocho-choledochostomy include ensuring that bile ducts have adequate blood supply and avoiding mechanical trauma or tension on the anastomosis. Techniques including ductoplasty and spatulation can be used to fashion an anastomosis even in the face of significant size mismatch between donor and recipient bile ducts. This article describes the technique of choledocho-choledochostomy in deceased donor liver transplantation.

Diagnosis and treatment of pheochromocytoma in an academic hospital from 1997 to 2007

BACKGROUND

The diagnosis and treatment of pheochromocytoma pose a challenge to physicians. Several trends in the presentation, diagnosis, and surgical treatment of pheochromocytoma have emerged in the last 10 years. The diagnostic accuracy and consequences of misdiagnosis of pheochromocytoma are not well known. We aimed to systemically study the diagnostic accuracy and treatment outcomes of pheochromocytoma and to reveal the causes and consequences of misdiagnosis (including both overdiagnosis and underdiagnosis).

METHODS

We reviewed the electronic and paper charts of 49 patients who underwent adrenalectomy or adrenal biopsy with either preoperative or pathologic diagnosis of pheochromocytoma in a large academic hospital from 1997 to 2007. Three groups of patients (overdiagnosed, correctly diagnosed, and underdiagnosed) were compared on clinical courses, biochemical tests, imaging studies, and surgical outcomes.

RESULTS

Pheochromocytoma was overdiagnosed in 9 patients, correctly diagnosed in 30 patients, and underdiagnosed in 10 patients. The overdiagnosis rate was 23% (9/39), and the underdiagnosis rate was 25% (10/40). The 3 distinct groups of patients exhibited significant differences in clinical presentation, biochemical tests, and imaging characteristics. The most common causes of overdiagnosis were misinterpretation of borderline biochemical test results and overzealous imaging. Overdiagnosis subjected patients to unnecessary adrenalectomy and its complications. The most common cause of underdiagnosis was failure to consider and test for pheochromocytoma. Underdiagnosis resulted in dangerous adrenal biopsy or adrenalectomy with hypertensive crisis and nearly doubled the length of stay in hospital. Surgical resection of correctly diagnosed pheochromocytoma was largely effective and safe, but intraoperative and postoperative complications occurred in some patients.

CONCLUSION

We conclude that misdiagnosis of pheochromocytoma is not uncommon and causes serious adverse effects. Correct interpretation of biochemical tests and imaging is crucial to a correct diagnosis, and pheochromocytoma should always be included in the differential diagnosis of any adrenal mass. Our data suggest that physician education is needed to improve the diagnosis and treatment of pheochromocytoma.

Completely laparoscopic nonanatomic hepatic resection using saline-cooled cautery and hydrodissection

The technical aspects of laparoscopic hepatic resection have evolved rapidly. The key to any approach is establishing a reliable method to prevent or control hemorrhage during parenchymal transection. Although combining a hand-assist technique with laparoscopy allows improved control of bleeding risk, this requires the addition of a hand-port incision. The development of novel devices that can be used to safely divide liver parenchyma laparoscopically may lessen the need for hand-assist. Here, we report a series of laparoscopic hepatic resections that were attempted without the use of hand-assistance (completely laparoscopic). Resections were performed using saline-cooled cautery (Tissue-Link Endohook) and/or hydrodissection (Erbe Helix Hydrojet). Fifteen laparoscopic hepatic resections were attempted by a single surgeon from 2002 to 2006. In each case, a nonanatomic, completely laparoscopic approach was attempted. Patients with lesions at the hepatic dome or those requiring lobectomy or hilar dissection were excluded. Fourteen of 15 cases (93%) were accomplished completely laparoscopically, while one patient required placement of a hand port. Resected tumors averaged 3.9 cm diameter. There were no bile leaks and no patient required transfusion. Average length of stay was 4.1 days (range 1-5). Complications included ileus (1) and atrial fibrillation (1). In six patients with malignancies, margins were negative and there have been no local or port recurrences. This report demonstrates the feasibility of completely laparoscopic hepatic resection using novel devices for parenchymal transaction. Hand-assist techniques remain useful as a salvage strategy or for larger resections.

Completely Laparoscopic Nonanatomic Hepatic Resection Using Saline-Cooled Cautery and Hydrodissection

The technical aspects of laparoscopic hepatic resection have evolved rapidly. The key to any approach is establishing a reliable method to prevent or control hemorrhage during parenchymal transection. Although combining a hand-assist technique with laparoscopy allows improved control of bleeding risk, this requires the addition of a hand-port incision. The development of novel devices that can be used to safely divide liver parenchyma laparoscopically may lessen the need for hand-assist. Here, we report a series of laparoscopic hepatic resections that were attempted without the use of hand-assistance (completely laparoscopic). Resections were performed using saline-cooled cautery (Tissue-Link Endohook) and/or hydrodissection (Erbe Helix Hydrojet). Fifteen laparoscopic hepatic resections were attempted by a single surgeon from 2002 to 2006. In each case, a nonanatomic, completely laparoscopic approach was attempted. Patients with lesions at the hepatic dome or those requiring lobectomy or hilar dissection were excluded. Fourteen of 15 cases (93%) were accomplished completely laparoscopically, while one patient required placement of a hand port. Resected tumors averaged 3.9 cm diameter. There were no bile leaks and no patient required transfusion. Average length of stay was 4.1 days (range 1–5). Complications included ileus (1) and atrial fibrillation (1). In six patients with malignancies, margins were negative and there have been no local or port recurrences. This report demonstrates the feasibility of completely laparoscopic hepatic resection using novel devices for parenchymal transaction. Hand-assist techniques remain useful as a salvage strategy or for larger resections.

Abdominal compartment syndrome secondary to retroperitoneal hematoma as a complication of ERCP after liver transplantation

Endoscopic retrograde cholangiopancreatography (ERCP) is frequently employed in the management of postoperative biliary complications in the liver transplant patient. Bleeding after ERCP most commonly presents as gastrointestinal bleeding and often can be managed with repeat endoscopy. ERCP can also be complicated by retroperitoneal hematoma, which in rare cases can lead to hemodynamic compromise due to relentless hemorrhage or from secondary abdominal compartment syndrome. We describe the first reported case of post-ERCP retroperitoneal hematoma in a liver transplant recipient that led to abdominal compartment syndrome and shock liver. We will present the case, discuss management, and review the complications of ERCP in the liver transplant recipient. Close post-procedure monitoring, rapid detection, and low threshold for decompressive laparotomy are keys to the successful management of the liver transplant recipient experiencing expanding retroperitoneal hematoma after ERCP.

Cavo-Atrial Tumor Resection Under Total Circulatory Arrest Without a Sternotomy

Surgical management of intracardiac tumors arising in the inferior vena cava often requires total circulatory arrest for safe and adequate resection. Total circulatory arrest has traditionally been accomplished by accessing the great vessels through a sternotomy. Combination of a sternotomy and a large abdominal incision results in excellent exposure but also creates the potential for significant morbidity. We report here the resection of cavoatrial tumors by achieving total circulatory arrest through femoral arterial and venous cannulation without requiring a sternotomy. This minimal-access total circulatory approach has the potential to greatly diminish morbidity when managing tumors of the inferior vena cava.

Pancreaticoduodenectomy after neoadjuvant therapy in a Jehovah's witness with locally advanced pancreatic cancer: case report and approach to avoid transfusion

Although the morbidity and mortality rates associated with pancreaticoduodenectomy (PD) have been improving over the past several decades, perioperative transfusions are often needed. Here, we review the preoperative planning and overall management of a Jehovah's Witness patient with locally advanced pancreatic cancer who would not accept blood transfusion. Management of this case is reviewed, along with the relevant literature regarding major surgery in the Jehovah's Witness population. The use of neoadjuvant chemoradiation was used successfully in locally advanced disease, allowing surgical resection. In addition, we outline a cogent strategy using pre-, intra-, and postoperative techniques to minimize blood loss and maintain hemoglobin at acceptable levels thereby preventing the need for transfusion. These strategies, once in place, may be able to reduce transfusions in all patients having major resections for malignancy.

Pancreaticoduodenectomy after Neoadjuvant Therapy in a Jehovah's Witness with Locally Advanced Pancreatic Cancer: Case Report and Approach to Avoid Transfusion

Although the morbidity and mortality rates associated with pancreaticoduodenectomy (PD) have been improving over the past several decades, perioperative transfusions are often needed. Here, we review the preoperative planning and overall management of a Jehovah's Witness patient with locally advanced pancreatic cancer who would not accept blood transfusion. Management of this case is reviewed, along with the relevant literature regarding major surgery in the Jehovah's Witness population. The use of neoadjuvant chemoradiation was used successfully in locally advanced disease, allowing surgical resection. In addition, we outline a cogent strategy using pre-, intra-, and postoperative techniques to minimize blood loss and maintain hemoglobin at acceptable levels thereby preventing the need for transfusion. These strategies, once in place, may be able to reduce transfusions in all patients having major resections for malignancy.

Living donor liver transplantation: histological abnormalities found on liver biopsies of apparently healthy potential donors

OBJECTIVE

With the continued shortage of deceased donor grafts, living donor liver transplantation has become an option for adult liver transplant candidates. In the non-transplant setting, liver biopsy is typically carried out to evaluate clinical or biochemical hepatic dysfunction. In living donor liver transplantation, assessment of histological abnormalities that are undetectable by serological, biochemical and radiological methods might play an important role in donor and recipient outcome.

METHODS

Seventy consecutive liver biopsies carried out as part of our evaluation of potential donor candidates for adult-to-adult or adult-to-child living donor liver transplants were analyzed.

RESULTS

Of the 70 potential donor candidates who underwent liver biopsy for evaluation for living donor liver transplantation, 67% had an unexpected abnormality, of which steatosis was the most common abnormality (38.5%). A variety of other histopathological abnormalities were found including granulomas of unknown etiology (7%), chronic hepatitis (6%) and a microabscess. None of the histological abnormalities had been suspected despite extensive clinical, serological or radiological investigation.

CONCLUSIONS

Among the 70 potential donor candidates for living donor liver transplantation, 34% had unremarkable liver biopsies. The most common abnormality was steatosis (38.5%). These findings suggest that all potential candidates for living donor liver transplants should undergo screening liver biopsies. The precise significance of these changes remains to be determined, including which of these changes are contraindications to liver transplantation. These findings may also have implications in the non-transplant setting as changes ascribed to specific etiologies for liver disease might include changes occurring in apparently healthy individuals.

Laparoscopic cholecystectomy in a patient with a biventricular cardiac assist device

Evaluation and management of abdominal pathology in patients with ventricular assist devices is likely to become increasingly important as the utilization of these devices expands. Ventricular assist devices represent a class of intracorporeal or paracorporeal mechanical devices that augment cardiac output in patients with congestive heart failure. Patients with ventricular assist devices supporting both right and left ventricles (biventricular assist devices) are uniquely challenging to the general surgeon because these devices restrict direct access to the abdominal cavity and because of the perioperative implications of biventricular heart failure. We describe herein the first reported successful laparoscopic cholecystectomy in a patient with a paracorporeal biventricular assist device. Cholecystectomy was performed in this patient for acute cholecystitis that occurred while the patient was awaiting heart transplantation. Our results add weight to the small body of evidence that laparoscopy is well tolerated in ventricular assist devices patients. The unique aspects of the biventricular assist device patient make laparoscopic abdominal intervention particularly suitable in this patient population.

Emerging Role of Transplantation for Primary Liver Cancers

Liver transplantation (LT) has been utilized in the treatment of primary hepatic malignancy for decades. Hepatocellular cancer (HCC) remains the most common malignant condition treated with LT, with almost 400 such transplants performed annually in the US. Refinement in the selection criteria for LT in patients with HCC has led to survival rates similar to those for LT in nonmalignant conditions. Excellent results have also been reported following LT for select patients with epithelioid hemangioendothelioma and hepatoblastoma. Patients with cholangiocarcinoma treated with LT have generally faired poorly, with survival rates far below that of LT for nonmalignant conditions. Improved survival has recently been reported following LT for cholangiocarcinoma in highly select patients treated with aggressive neoadjuvant therapy. The future utility of LT in the treatment of malignancy will be influenced by several factors, including a profound organ donor shortage faced worldwide; increasing prevalence of hepatitis C, HCC and cirrhosis; and the evolution of live donor liver transplantation.

Differential angiogenic and proliferative activity of surgical and burn wound fluids

BACKGROUND

Invasive surgical wounds exhibit the rapid production of a robustly proangiogenic environment. To compare the immediate angiogenic environment of wounds of different types, the angiogenic activity of fluid derived from burn injuries and wounds confined to the dermis was examined and compared with that of deeper surgical wounds.

METHODS

The angiogenic activity of surgical wound fluid (SWF) (n = 7), skin graft wound fluid (SGF) (n = 3), and burn wound fluid (BWF) (n = 4) was assessed by measuring endothelial cell (EC) proliferative activity, EC chemotactic activity, and angiogenic activity in the rat corneal assay. The fibroblast growth factor-2 (FGF-2) level of each wound fluid was determined by enzyme-linked immunosorbent assay.

RESULTS

SWF exhibited significant EC proliferative activity, SGF exhibited intermediate activity, and BWF displayed no EC proliferative activity. Seventy-one percent of SWF samples, 33% of SGF, and 0% of BWF contained significant EC chemotactic activity. Each wound fluid sample that demonstrated significant chemotactic activity also evoked a positive corneal angiogenic response. SWF contained 914 +/- 170 pg/mL of FGF-2, whereas SGF and BWF contained just 164 +/- 54 pg/mL and 37 +/- 7 pg/mL of FGF-2, respectively.

CONCLUSION

The results suggest that injuries confined to the dermis, whether thermal or excisional, elicit a less robust initial angiogenic stimulus than deep surgical wounds.

Hepatocellular carcinoma: the high-risk patient

Hepatocellular carcinoma (HCC) is the most common hepatic malignancy worldwide. The primary risk factor for the development of HCC is cirrhosis. Even patients without cirrhosis who develop HCC are typically found to have some underlying hepatic abnormality, such as steatohepatitis or chronic viral hepatitis. Although cirrhosis of any cause increases the risk of developing HCC, cirrhosis associated with chronic hepatitis B or C virus infection or hemochromatosis carries the greatest risk. Additional factors such as patient age and sex, duration and severity of liver disease, concurrent alcohol or aflatoxin exposure, liver histology, and alpha-fetoprotein levels also contribute to the relative risk of developing HCC. Vaccination programs aimed at preventing hepatitis B virus infection have been very successful in lowering the incidence of HCC in some areas of the world. Interferon-based therapy, which may control the inflammatory activity in chronic hepatitis C, also holds promise in preventing HCC. Other novel chemopreventative agents, such as glycyrrhizin and polyprenoic acid, may also have a role in preventing HCC, but they require further study before they can be recommended for widespread use.

Heparin and heparan sulphate protect basic fibroblast growth factor from non-enzymic glycosylation

Non-enzymic glycosylation of basic fibroblast growth factor (bFGF, FGF-2) has recently been demonstrated to decrease the mitogenic activity of intracellular bFGF. Loss of this bioactivity has been implicated in impaired wound healing and microangiopathies of diabetes mellitus. In addition to intracellular localization, bFGF is also widely distributed in the extracellular matrix, primarily bound to heparan sulphate proteoglycans (HSPGs). Nonetheless, it is not clear if non-enzymic glycosylation similarly inactivates matrix-bound bFGF. To investigate this, we measured the effect of non-enzymic glycosylation on bFGF bound to heparin, heparan sulphate and related compounds. Incubation of bFGF with the glycosylating agents glyceraldehyde 3-phosphate (G3P; 25 mM) or fructose (250 mM) resulted in loss of 90% and 40% of the mitogenic activity of bFGF respectively. Treatment with G3P and fructose also decreased the binding of bFGF to a heparin column. If heparin was added to bFGF prior to non-enzymic glycosylation, the mitogenic activity and heparin affinity of bFGF were nearly completely preserved. A similar protective effect was demonstrated by heparan sulphate, low-molecular-mass heparin and the polysaccharide dextran sulphate, but not by chondroitin sulphate. Whereas non-enzymic glycosylation of bFGF with G3P impaired its ability to stimulate c-myc mRNA expression in fibroblasts, no such impairment was noticeable when bFGF was glycosylated in the presence of heparin. Taken together, these results suggest that HSPG-bound bFGF is resistant to non-enzymic glycosylation-induced loss of activity. Therefore, alteration of this pool probably does not contribute to impaired wound healing seen in diabetes mellitus.

Vascular endothelial growth factor mediates angiogenic activity during the proliferative phase of wound healing

Angiogenesis is an essential component of normal wound repair, yet the primary mediators of wound angiogenesis have not been well described. The current study characterizes the contribution of vascular endothelial cell growth factor (VEGF) to the angiogenic environment of human surgical wounds. Surgical wound fluid samples (n = 70) were collected daily for up to 7 postoperative days (POD) from 14 patients undergoing mastectomy or neck dissection. VEGF levels in surgical wound fluid were lowest on POD 0, approximating values of serum, but increased steadily through POD 7. An opposite pattern was noted for basic fibroblast growth factor-2. Fibroblast growth factor-2, which has been previously described as a wound angiogenic factor, exhibited highest levels at POD 0, declining to near serum levels by POD 3. Surgical wound fluid form all time points stimulated marked endothelial cell chemotaxis and induced a brisk neovascular response in the rat corneal micropocket angiogenesis assay. Antibody neutralization of VEGF did not affect the in vitro chemotactic or the in vivo angiogenic activity early wound samples (POD 0). In contrast, VEGF neutralization significantly attenuated both chemotactic activity (mean decrease 76 +/- 13%, P < 0.01) and angiogenic activity (5 of 5 samples affected) of later wound samples (POD 3 and 6). The results suggest a model of wound angiogenesis in which an initial angiogenic stimulus is supplied by fibroblast growth factor-2, followed by a subsequent and more prolonged angiogenic stimulus mediated by VEGF.

Thrombospondin 1 synthesis and function in wound repair

Thrombospondin 1 (TSP1) is a multifunctional extracellular matrix molecule that belongs to a family of homologous glycoproteins. TSP1 can be produced by many cell types that are involved in wound repair, including keratinocytes, fibroblasts, endothelial cells, and macrophages. To investigate the kinetics of TSP1 synthesis in wounds, mRNA from murine full thickness excisional dermal wounds was analyzed. TSP1 mRNA was undetectable in normal skin but was present in early wounds. After day 1, TSP1 mRNA levels within wounds slowly decreased, returning to undectable day 10. In situ hybridization revealed that the primary source of the TSP1 mRNA within wounds was macrophage-like cells in the inflammatory infiltrate. To explore the function of TSP1 production in sites of injury, wounds were treated with antisense TSP1 oligomers. Antisense-treated wounds contained 55 to 66% less TSP1-positive macrophages than control and exhibited a marked delay in repair. This delay included a decreased rate of re-epithelialization as well as a delay in dermal reorganization. The results suggest that TSP1 production by macrophages facilitates the repair process and provide evidence that TSP1 production is an important component of optimal wound healing.

Basic fibroblast growth factor mediates angiogenic activity in early surgical wounds

BACKGROUND

Wound angiogenesis is believed to be initiated by the early rapid release of performed growth factors such as basic fibroblast growth factor (bFGF). However, neither the angiogenic environment of early surgical wounds nor the potential contribution of bFGF to early surgical wound angiogenesis has been investigated.

METHODS

We collected surgical drain fluid (SDF) from closed suction drains 6 hours to 6 days after operation. SDF was tested for endothelial cell (EC) proliferative and chemotactic activity and for the capacity to stimulate angiogenesis in vivo in the rat corneal assay. bFGF levels of SDF were determined with enzyme-linked immunosorbent assay. Neutralizing antibody to bFGF was used to determine the contribution of bFGF to SDF activity.

RESULTS

The EC proliferative activity of SDF was maximal on postoperative day 0 (POD 0, 390% that of normal serum) and then fell by 41% on POD 1 and to near serum levels thereafter. SDF from PODs 0 and 1 also showed marked EC chemotactic activity and stimulated rapid formation of new vessels without signs of inflammation when implanted into rat corneas. The temporal appearance of bFGF in these exudates showed a pattern similar to EC proliferative activity, peaking on POD at 854 pg/ml and decreasing 80% by POD 2. Neutralizing antibody to bFGF decreased he proliferative activity of SDF from PODs 0 and 1 to near serum levels and substantially decreased the chemotactic and the in vivo neovascular response to SDFs.

CONCLUSIONS

Surgical wounds are characterized by a rapid and early angiogenic environment that is mediated in part by bFGF, suggesting that tissue or platelet stores of bFGF may initiate wound repair.