Intestinal transplantation: living related

The use of live donors in intestinal transplantation could potentially both reduce the severity of rejection responses against this highly immunogenic organ by better tissue matching and also reduce cold ischaemia times. These two advantages over cadaveric grafts could preserve mucosal integrity and reduce the risk of systemic sepsis from bacterial translocation. The disadvantages of live donation are the inherent risk to the donor and the compromise of using a shorter graft. Although only a handful of such cases have been performed, the success rate has been high and this is a therapeutic modality which should be explored further.

Combined orthotopic liver transplantation and caesarean section for the Budd-Chiari syndrome

Fulminant hepatic failure is a rare complication of pregnancy. We describe a case of Budd-Chiari syndrome that resulted in the need for combined liver transplantation and Caesarean section at 32 weeks' gestation. The anaesthetic and perioperative management are discussed.

The development of spontaneous colo-umbilical fistula

A patient with colo-umbilical fistula is reported. This presentation is unique because it documents the development of a fistula from a colonic diverticulum. Sigmoid colectomy was undertaken successfully.

An evaluation of the cyclosporine parent-compound-specific whole blood TDx assay

The new Abbott TDx cyclosporine parent-compound-specific fluorescence polarization immunoassay (TDxP) was evaluated and compared to the cyclosporine-and-metabolites-specific TDx (TDxT) and a cyclosporine parent-compound-specific radioimmunoassay (RIA) (Sandimmun-Kit, INCSTAR). The TDxP assay was linear within the range of 31 to 1600 ng/ml (r = 0.985) with a lower limit of detection of less than 31 ng/ml. The TDxP had excellent intra- and interassay reproducibility (CV = 1.2 to 4.5) that was significantly better than that of the radioimmunoassay. 230 whole blood samples obtained from 65 kidney, 19 liver, and 8 pancreas transplant recipients were analyzed with each of the three assay methods. TDxP had a much stronger correlation with the RIA than did TDxT (r = 0.95 versus 0.83). The difference between the correlations was greatest for the liver and pancreas recipients. The mean ratio of the cyclosporine level determined by TDxP to RIA was 1.0 versus 2.4 for TDxT to RIA. The new TDxP assay provides results equal to a parent-compound-specific RIA but with the added advantages of decreased sample turn-around time and improved intra- and interassay coefficients of variation.

Breast sarcoma. A clinicopathologic review of 25 cases

Sarcoma of the breast represents less than 1% of primary mammary malignancies; this study reports 25 such cases. The largest group had malignant fibrous histiocytoma (44%), followed by liposarcoma (24%) and fibrosarcoma (16%). Also represented were clear cell sarcoma, neurogenic sarcoma, leiomyosarcoma, and alveolar soft part sarcoma (4% each). Of 19 patients treated by wide local excision or simple mastectomy with or without adjuvant radiotherapy, 11 had local recurrence develop, of which one patient died and nine of the remaining ten had metastases develop. Of the remaining eight patients in this group with no local recurrence, only two had metastases develop. Of the six patients treated by radical or Patey mastectomy, none had local recurrence develop, but two died of metastases. No patient had metastases develop more than 5 years after diagnosis. Regional lymph node involvement with tumor was observed in only one patient (with malignant fibrous histiocytoma) despite regional lymphadenopathy in seven. The overall mortality at 5 years is 64% but does not increase thereafter. The authors' findings suggest that failure to establish local control is associated with a poor prognosis and that wide local excision or simple mastectomy does not provide sufficient clearance to be used as first-line treatment. Excision of the axillary lymphatics and adjuvant radiotherapy are unlikely to be beneficial.

Breast sarcoma. A clinicopathologic review of 25 cases

Sarcoma of the breast represents less than 1% of primary mammary malignancies; this study reports 25 such cases. The largest group had malignant fibrous histiocytoma (44%), followed by liposarcoma (24%) and fibrosarcoma (16%). Also represented were clear cell sarcoma, neurogenic sarcoma, leiomyosarcoma, and alveolar soft part sarcoma (4% each). Of 19 patients treated by wide local excision or simple mastectomy with or without adjuvant radiotherapy, 11 had local recurrence develop, of which one patient died and nine of the remaining ten had metastases develop. Of the remaining eight patients in this group with no local recurrence, only two had metastases develop. Of the six patients treated by radical or Patey mastectomy, none had local recurrence develop, but two died of metastases. No patient had metastases develop more than 5 years after diagnosis. Regional lymph node involvement with tumor was observed in only one patient (with malignant fibrous histiocytoma) despite regional lymphadenopathy in seven. The overall mortality at 5 years is 64% but does not increase thereafter. The authors' findings suggest that failure to establish local control is associated with a poor prognosis and that wide local excision or simple mastectomy does not provide sufficient clearance to be used as first-line treatment. Excision of the axillary lymphatics and adjuvant radiotherapy are unlikely to be beneficial.

Liver transplantation in cancer--a review

Whilst liver transplantation is an accepted therapeutic modality for end stage cirrhosis, its application for hepatic malignancy has remained a controversial issue. This is due to the early experience in several centres of tumour recurrence within the first year. More recently, stringent patient selection criteria have been established to decrease the risk of tumour recurrence. Pre-operative assessment including liver biopsy, computerised axial tomography (CT) of both the thorax and abdomen, bone scans and pre-transplant laparotomy are routinely performed to exclude extrahepatic spread. Of the primary tumours, the most common groups are the hepatocellular carcinomas (HCC) and cholangiocarcinomas. A hierarchy of tumours favourable for transplantation exists, with HCC giving the best results, followed by central bile duct carcinoma, cholangiocellular carcinoma (peripheral), and secondaries, in descending order of suitability. With better patient selection based on adequate staging, and the confinement of liver grafting to lymph node negative stages, there has been a marked improvement in survival in otherwise unresectable and mainly untreatable tumours. The improved results support the application of liver grafting for malignancy, and suggest that the often discussed danger of tumour growth enhancement because of immunosuppression may not significantly be present. Despite the risk of tumour recurrence, liver transplantation gives worthwhile survival with the chance of cure for some and in others, considerable palliation with prolonged survival.

Surgery for recurrent colorectal carcinoma--is it worthwhile?

A series of 45 patients undergoing a second operation for recurrent colorectal cancer is reported. The majority developed recurrence within 2 years of their initial surgery. Despite regular follow-up, in only 27% of patients submitted to further surgery was the recurrence detected at routine review, and only three of these were asymptomatic at the time of diagnosis. A potentially curative second procedure was undertaken in 47% of cases, with a 2-year survival of 71% and a 5-year survival of 29%. Of those undergoing palliative surgery, this was worthwhile in 64%, providing palliation for more than 6 months. Mean survival following a palliative procedure was 10 months. Palliation was better, and operative mortality lower, when the bulk of the tumour could be removed. In obstructed patients the outcome following palliative resection was better than for palliative bypass procedures. Following resection of metastases there is the prospect of long-term survival, but it is difficult to predict those patients who will do well.