Use of Extended Right Grafts From In Situ Split Livers in Adult Liver Transplantation: A Comparison With Whole-Liver Transplants

INTRODUCTION

We report our experience of in situ split-liver transplantation (SLT) for adult patients and compare the results with those achieved with whole-liver transplantation (WLT).

METHOD

From November 1997 to December 2003, 109 liver transplantation were performed in 104 adult patients including 90 WLT (83%) and 19 SLT (17%) grafts. Fifteen extended right grafts (ERG, segments I + IV to VIII) were obtained with in situ split-liver procedures, generating also left lateral segment grafts, which were transplanted at our institution or elsewhere. Four left lobe (LL, segments I to IV) and right lobe (segments V to VIII) grafts were obtained by a modified in situ procedure for adult recipients. UNOS status, percentage of primary or secondary transplantation, and underlying liver disease were similar among patients receiving whole versus split grafts. Donors were older in whole than ERG cohorts (53 vs 26 years, P < .001). Procurement parameters and intraoperative profiles of transplant procedure were comparable among the groups.

RESULTS

Median follow-up was 18 months (range: 1 to 73). Four patients with whole (4%) and no patient with ERG underwent retransplantation (P = NS). One- and 3-year patient survivals were 86% and 79% with WLT versus 93% and 93% with ERG (P = NS). One- and 3-year graft survivals were 84% and 75% with WLT versus 93%, and 93% with ERG (P = NS). Incidence of vascular complications was 8% with WLT, 13% with ERG (P = NS). The incidence of biliary complications was 13% in WLT, 27% in ERG (P = NS).

CONCLUSIONS

The use of ERG from in situ split livers for adult transplantation allowed us to obtain results comparable or even better than those obtained with WLT. Split-liver transplantation is an effective, safe mechanism to expand the cadaveric donor pool.

[Thyroid nodule pathology: proposal of a diagnostic approach based on the experience of a thyroid disease unit]

Thyroid nodules are commonly found in clinical practice, and their detection by either the physician or the patients always gives rise to concern as to the possible existence of a malignancy. Technological developments have had a major impact on the study and treatment of thyroid nodules. The application of fine-needle aspiration biopsies (FNAB) and the availability of high-resolution thyroid ultrasonography have modified thyroid nodule management even if important differences of opinion remain. This article describes the progress as well as contemporary controversies in thyroid nodule diagnosis and considers the effect these advances have had on the treatment of patients with nodular disease. It includes a brief description of the clinical importance of thyroid nodules, of the use and limitations of imaging studies in thyroid nodule diagnosis and of the usefulness, limitations, and impact of FNAB on nodule management.

Bioremediation of a soil contaminated by hydrocarbon mixtures: the residual concentration problem

The phenomenon of residual concentration was investigated in the aerobic biodegradation of three different petroleum commercial products (i.e., kerosene, diesel fuel and a lubricating mineral oil) in static microcosms. Two different soils exhibiting different physical-chemical characteristics were used (i.e., a biologically treated hydrocarbon-contaminated soil and a pristine soil). Residual concentrations were observed and a simple way to take this phenomenon into account was proposed.

[The current indications for Madden's radical mastectomy in our experience. A critical review of 201 consecutive patients]

The clinical pathological data regarding the 201 patients (203 operations running) who underwent radical mastectomy according to Madden in the II Division of General Surgery at Brescia Civil Hospital in the period 1993-1994, have been reexamined in order to check the real need of radical surgery. This further analysis, apart from the patients with neoplasias of considerable dimensions (T2; > 2 cm), has been carried out on 100 tumors smaller dimensions (T1; < 2 cm) and has confirmed the necessity of radical surgery in 87 cases. Of the 13 operations (6.4%) that have been considered "improper" 2 were due to erroneous clinical staging (dubious cutaneous infiltration) and 5 (2.5%) presented a neoplastic diameter of exactly 2 cm which only partially justified radical surgery. In six patients (2.9%) we haven't found clinical pathological elements which contraindicated conservative surgery.

[Impact of a screening program on the surgical treatment of breast carcinoma]

Results are presented concerning the first two cycles of a breast cancer screening program carried out by USSL 41 (the local social health center). 38,000 women were examined in a period ranging from 1987 to 1993 and more than 250 early stage tumors were diagnosed. Early detection by screening is confirmed by tumor size and nodal involvement. Overall, this program carried out in Brescia met requirements set by international and national scientific committees. Good results were obtained as far as quality standards are concerned. The importance of screening is evaluated concerning surgical treatment undergone by the patients. The study of surgical treatment clearly shows the gradual progression of conservative surgery deviating from more destructive operations.

[Diagnostic role of mammography and clinical examination in the framework of a screening program for breast carcinoma in Brescia]

Screening by mammography is at present the only way to obtain good results in terms of diagnosis of breast cancer at an early stage. In this paper we present the results of first and second rounds of a mammographic and clinical screening programme carried out in the health district of Brescia. At the first round out of 129 cancers detected, mammography was diagnostic in 124 cases; in 82 cases, the examination also allowed the identification of a suspicious nodule, while in 42 cases non palpable neoplasm was diagnosed with mammography alone. In the remaining 5 cases mammography was negative and only clinical examination led to the discovery of breast neoplasms. In the second round, in the 125 cancers detected, mammography was diagnostic in 124 cases; clinical examination allowed the identification of 59 of these tumours, while in 65 cases non palpable tumours were found with mammography alone. Only in one case mammography was negative and clinical examination led to the identification of the tumour.

[Intestinal anastomosis with biodegradable ring]

The authors report their experience using biofragmentable anastomosis ring (BAR) in bowel anastomosis. Starting January 1993 to February 1994, 46 intestinal anastomoses were performed using BAR, and particularly 39 end-to-end colo-colostomies, 2 end-to-side colo-colostomies and 5 end-to-side ileo-colostomies. 35 patients were affected by colonic neoplasm, 5 patients by diverticular colonic complications- and 5 patients by several unusual bowel diseases. Four emergency operations were performed, while 42 patients had an accurate bowel preparation before surgery. In this series of patients one case of preoperative mortality is reported, due to massive pulmonary embolism. Instead several minor complications occurred in other patients, such as paroxysmal atrial fibrillation (one case), basal pleuritis (one case), hyperpyrexia (three cases), temporary subocclusion or delayed canalization (five cases). Only one patient suffered from intestinal occlusion induced by adhesions and a second laparotomy was required. Delayed canalization seems to be caused by the small size of the BAR employed (25 mm) or by inadequate intestinal preparation, that usually occurs in emergency operations. After surgery all patients were followed up and 18 of them were examined by coloscopy six months after surgery. No clinical problem connected with bowel anastomosis was reported and all anastomosis looked quite previous and resilient. No anastomotic stenosis was found. In our experience and from recent reviewed reports, BAR seems to be a rapid, effective and safe device for sutureless bowel anastomosis.

[Role of surgery in the treatment of acute hemorrhagic non-variceal lesions in the upper gastrointestinal tract]

From January 1993 to December 1994, out of 244 cases of upper gastrointestinal hemorrhage observed 25 patients underwent surgical treatment. Twenty-nine bleeding varices were excluded from this study. Early endoscopy revealed the source of bleeding almost in all cases (84%). All patients received, at the time of admission, medical treatment associated in 7 cases (28%) to endoscopic injection therapy. Emergency surgery indications were massive bleeding persistent bleeding, rebleeding and macroscopic findings of lesions. The aim of this report is to verify the respective roles of medical, endoscopic and surgical therapies in relation to the nature of the bleeding lesion and the entity of the hemorrhage. Results with regard to indication, clinical data, surgical technique were compared with literature data.

[Solitary splenic metastasis of bladder carcinoma. Report of a clinical case]

Several authors assumed that spleen was resistant to neoplastic dissemination because of spleen metastasis are rare in relation to the incidence of metastasis in other parenchymatous organs. We report a clinical case of a symptomatic solitary spleen metastasis in cystic-looking bladder cancer; afterwards we'll examine real incidence of secondary splenic injury. In autopsy studies, the incidence of splenic metastatic spread is in contrast with the rarity of clinical manifestations of solitary metastasis. The case reported is really uncommon: a voluminous single metastasis, cystic-looking, with splenomegaly, abdominal pain and rapid onset. In the presence of a high malignancy primitive tumor, the evaluation of the effective utility of the surgical treatment carried out is premature, because of the relatively short follow-up. On the other hand, the painful symptomatology, the risk of disruption in peritoneal cavity, the impossibility to make inquiries about the nature of the cystic mass, imposed, in our opinion, a surgical treatment.

Intraoperative liver biopsy with the loop electrosurgical excision procedure in patients with gynecologic malignancies

When patients with gynecologic malignancies undergo exploratory surgery, hepatic lesions suggestive of malignancy are occasionally encountered. In 18 patients undergoing laparotomy for gynecologic cancer, visible liver lesions suggestive of malignancy were biopsied with the loop electrosurgical excision procedure (LEEP). Hemostatic suture placement was required in 3 of these 18 patients, and in 15, hemostasis was achieved with electrocautery only. Three of the 18 biopsies (16.7%) were positive for malignancy. No intraoperative or postoperative complications were attributed to the liver biopsy. One patient required postoperative transfusion of 2 units packed red blood cells. A new technique is described using the LEEP to remove suspicious lesions during exploratory laparotomy in patients with gynecologic malignancies.

[Thyroid carcinoma in hyperthyroid syndromes]

The relationship between hyperthyroidism and carcinoma of the thyroid is still uncertain. The incidence of thyroid carcinoma ranges from 0.3 to 16.6%. Between 1984 and 1994 the Authors observed 9 patients affected with thyroid cancer and toxic nodular goiter (4 patients) or Basedow disease (2 patients) or scintigraphic evidence of single hyperfunctioning nodule (3 patients). Six out of the 9 cases were diagnosed as papillary cancer, while three as follicular cancer. A carcinoma was diagnosed before operation in only one case, while in the other 8 patients, the diagnosis was obtained by histological examination of the specimen. Four patients underwent subtotal thyroidectomy, while five patients underwent radical lobectomy. All patients are alive and in good health; the average follow-up was 48 months.

[Conservative surgery in the environment of a screening program for breast carcinoma: evaluation of the results in terms of local recurrence]

This report evaluates the results of conservative surgery plus radiotherapy (QUART) in a group of 123 patients from the screening programme of the District Health Board USSL 41 in Brescia, Italy (over 250 tumours diagnosed in two screening rounds, between 1987 and 1993). To date no recurrence of neoplasms in the operated breast have been diagnosed in either of the two QUART groups (64 patients from the first round, average follow-up 28 months, median 66 months; 59 patients from the second round, average follow-up 28 months, median 30 months). A new carcinoma in the contralateral breast occurred in 3 patients (2 from the first and 1 from the second round), while in 3 cases there was a recurrence in another site (2 from the first and 1 from the second round). These results confirm both the proven effectiveness of conservative treatment in the local control of breast tumours, and the importance of the correct choice of conservative treatment in optimising aesthetic and therapeutic results.

Superior mesenteric artery emboli during renal PTA: successful surgical treatment after fibrinolysis failure

The paper presents a rare case of iatrogenic embolization of the superior mesenteric artery which required an emergency operation after an unsuccessful fibrinolytic treatment. An old woman, who had undergone renal percutaneous angioplasty (r-PTA), presented sudden but transient abdominal pain. Angiographic control of the angioplasty showed the goal of r-PTA but also an embolic occlusion of the main trunk of the superior mesenteric artery that did not respond to a selective fibrinolytic treatment. Within a few hours, the abdominal pain appeared again and induced an exploratory laparotomy which showed an extensive ischaemia of the whole jejunum. A successful embolectomy was performed associated with the resection of about 20 cm of necrotic jejunum. The postoperative period was uncomplicated. The case underlines several topics: close collaboration is necessary between interventional radiologists and surgeons in order to get a surgical "stand-by" during PTA procedures; the embolic occlusion of the superior mesenteric artery can produce irreversible, even if segmentary intestinal damage, also within a very short time after onset and, therefore, it seems to be at high risk for a fibrinolytic approach.

[Intra- and postoperative changes in blood viscosity]

Blood and plasma viscosity has been controlled in a group of patients undergone to aorto-iliac reconstruction and in a group of control after thyroidectomy, cholecystectomy, and hernioplasty. The hemodilution induced by intraoperative infusion in the vascular reconstruction produced an important decrease of hematic and plasmatic viscosity which lasted for several days after the operation. Removing the hemodilution effect by a mathematical correction of the viscosity measured values to a standard haematocrit, it has demonstrated as surgical operation, apart from its entity, promoted an increase of the viscosity which persisted long in the postoperative course. For what it concerns the risk of postoperative thrombosis from one side protective effect of hemodilution is confirmed, from the other, in absence of the hemodilution, it would be useful to continue the antithrombotic prophylaxis longer the perioperative time as usual.