A 3-month course of long-acting repeatable octreotide (sandostatin LAR) improves portal hypertension in patients with cirrhosis: a randomized controlled study

OBJECTIVE

In patients with cirrhosis, acute octreotide administration may transiently decrease the hepatic venous pressure gradient (HVPG). Information on long-term effects of octreotide is limited and controversial. We evaluated portal and systemic hemodynamics following a prolonged administration of long-acting octreotide in patients with cirrhosis.

METHODS

Eighteen cirrhotic patients (alcoholic 12; age 55 yr [44-69]; Pugh's score 7.8; HVPG 17.3 mmHg [12-22]), no steatohepatitis on histology, were randomized to intramuscular octreotide 20 mg (group A) q 4 wk for 3 months or placebo (group B) in a double-blind fashion. At baseline and 3 months, we measured the HVPG, systemic hemodynamics, endothelin-1 (ET-1), and vascular endothelial growth factor (VEGF) in hepatic venous blood.

RESULTS

Patients remained compensated except for one episode of infection in each group. At 3 months, the HVPG decreased in group A but not in group B (16.5 +/- 1.3 to 11.8 +/- 1.5 mmHg, P < 0.01; 18.2 +/- 1 to 17 +/- 1.1 mmHg, P= 0.4). Systemic hemodynamics and liver function remained unchanged. In group A, but not in group B, VEGF decreased (21.2 +/- 4.7 to 13.7 +/- 3.5 pg/mL, P < 0.01; 22.5 +/- 7.8 to 19.2 +/- 5.4 pg/mL, P= 0.4). ET-1 remained stable. Changes in HVPG and VEGF were correlated (r = 0.49, P < 0.05).

CONCLUSIONS

Three months of long-acting octreotide in selected cirrhotic patients with portal hypertension decreases the HVPG independent of systemic hemodynamics and liver function. The decrease in VEGF blood levels suggests an improvement in splanchnic hyperemia.

Vascular invasion in pancreatic cancer: evaluation of endoscopic ultrasonography, computed tomography, ultrasonography, and angiography

PRINCIPLES

Current methods for detecting vascular invasion in pancreatic cancer can be inaccurate, invasive, and expensive. The aim of this study is to assess the value of current imaging modalities in determining vascular invasion by pancreatic cancer.

METHODS

The results of Endoscopic Ultrasonography (EUS), Computed Tomography (CT), Ultrasonography (US), and Angiography performed in 170 patients, suffering from pancreatic cancer, were retrospectively studied and correlated with intra-operative findings and surgical anatomopathological diagnosis after resection. We assessed sensitivity, specificity, positive and negative predictive values, and accuracy for detecting vascular invasion.

RESULTS

EUS turned out to be the most reliable imaging technique for detecting vascular invasion in pancreatic cancer, with a sensitivity of 55%, specificity of 90%, positive predictive value of 61.1%, negative predictive value of 87.5%, and accuracy of 82.2%. CT results were 39.4%, 90%, 52%, 84.4%, and 79.1% for the respective categories, with however, better results with multislice CT. The US results were 3.7% for the sensitivity, 96.3% for the specificity, 25% for the positive predictive value, 75.2% for the negative predictive value, and 73.4% for the accuracy. For angiography, the sensitivity, the specificity, the positive predictive value, the negative predictive value, and the accuracy were 52.6%, 72.3%, 43.5%, 79.1%, and 66.7% respectively.

CONCLUSION

In this study, EUS was the most valuable imaging modality in assessing vascular invasion (especially for venous invasion) for pancreatic cancer, with an accuracy of more than 80%. A further prospective study should be carried out to evaluate the combination of imaging modalities for the detection of vascular involvement, especially with multi-slice CT which almost reached the performances obtained by EUS.

Lessons learned from one thousand consecutive colonic resections in a teaching hospital

Elective colectomies are standard procedures carrying below 1% mortality; by contrast, emergency colonic resections remain surgical challenges in compromised and/or elderly patients and are associated with high complication rates.

Conversion to sirolimus-based immunosuppression in maintenance liver transplantation patients

Sirolimus (SRL) has been proposed to replace calcineurin inhibitors (CNI) in case of CNI-induced toxicity. The aim of this study was to evaluate the efficacy and safety of conversion from CNI to SRL in maintenance liver transplantation (LT) patients. Between 2002 and 2006, conversion was performed in 48 patients (17 female, 31 male; mean age 57 +/- 10 yr) after a median delay of 19.4 months (range 0.2-173 months) after LT. Indication for conversion was renal impairment (RI) (78%), CNI neurotoxicity (13%), or post-LT cancer (9%). Median follow-up was 22.6 +/- 11 months. Median SRL dosage and trough levels were 2.4 +/- 1.3 mg and 8.1 +/- 2.7 microg/L. Immunosuppression consisted of SRL alone (33%), or SRL + mycophenolate mofetil (MMF) (39%), SRL + prednisone (15%), SRL + CNI (4%), or SRL + MMF + prednisone (8%). Mean glomerular filtration rate (GFR) improved from 33 to 48 mL/minute in patients with severe RI (P = 0.022) and from 56 to 74 mL/minute in patients with moderate RI (P = 0.0001). After conversion, main complications were albuminuria (36%), hyperlipidemia (49%), dermatitis (14%), edema (14%), oral ulcers (12%), joint pain (4%), infection (2%), and pneumonia (2%). Acute rejection (AR) occurred in 17% of the patients. SRL was withdrawn in 17% of the patients. In conclusion, conversion from CNI to SRL is safe and is associated with significant renal function improvement.

Image-guided multipolar radiofrequency ablation of liver tumours: initial clinical results

The local effectiveness and clinical usefulness of multipolar radiofrequency (RF) ablation of liver tumours was evaluated. Sixty-eight image-guided RF sessions were performed using a multipolar device with bipolar electrodes in 53 patients. There were 45 hepatocellular carcinomas (HCC) and 42 metastases with a diameter < or =3 cm (n = 55), 3.1-5 cm (n = 29) and >5 cm (n = 3); 26 nodules were within 5 mm from large vessels. Local effectiveness and complications were evaluated after RF procedures. Mean follow-up was 17 +/- 10 months. Recurrence and survival rates were analysed by the Kaplan-Meier method. The primary and secondary technical effectiveness rate was 82% and 95%, respectively. The major and minor complication rate was 2.9%, respectively. The local tumour progression at 1- and 2-years was 5% and 9% for HCC nodules and 17% and 31% for metastases, respectively; four of 26 nodules (15%) close to vessels showed local progression. The survival at 1 year and 2 years was 97% and 90% for HCC and 84% and 68% for metastases, respectively. Multipolar RF technique creates ablation zones of adequate size and tailored shape and is effective to treat most liver tumours, including those close to major hepatic vessels.

Resection of hepatic colorectal metastases involving the caudate lobe: perioperative outcome and survival

PURPOSE

To examine clinical features and outcome of patients who underwent hepatic resection for colorectal liver metastases (LM) involving the caudate lobe.

PATIENTS AND METHODS

Consecutive patients who underwent hepatic resection for LM from May 1990 to September 2004 were analyzed from a multicenter database. Demographics, operative data, pathologic margin status, recurrence, and survival were analyzed.

RESULTS

Of 580 patients, 40 (7%) had LM involving the caudate. Six had isolated caudate LM and 34 had LM involving the caudate plus one or more other hepatic segments. Patients with caudate LM were more likely to have synchronous primary colorectal cancer (63% vs. 36%; P = 0.01), multiple LM (70% vs. 51%; P = 0.02) and required extended hepatic resection more often than patients with non-caudate LM (60% vs. 18%; P < 0.001). Only four patients with caudate LM underwent a vascular resection; three at first operation, one after recurrence of a resected caudate tumor. All had primary repair (vena cava, n = 3; portal vein, n = 1). Perioperative complications (43% vs. 28%) and 60-day operative mortality (0% vs. 1%) were similar (caudate vs. non-caudate LM, both P > 0.05). Pathological margins were positive in 15 (38%) patients with caudate LM and in 43 (8%) with non-caudate LM (P < 0.001). At a median follow-up of 40 months, 25 (64%) patients with caudate LM recurred compared with 219 (40%) patients with non-caudate LM (P = 0.01). Patients with caudate LM were more likely to have intrahepatic disease as a component of recurrence (caudate: 51% vs. non-caudate: 25%; P = 0.001). No patient recurred on the vena cava or portal vein. Patients with caudate LM had shorter 5-year disease-free and overall survival than patients with non-caudate LM (disease-free: 24% vs. 44%; P = 0.02; overall: 41% vs. 58%; P = 0.02).

CONCLUSIONS

Patients who undergo hepatic resection for caudate LM often present with multiple hepatic tumors and tumors in proximity to the major hepatic veins. Extended hepatectomy is required in the majority, although vascular resection is not frequently necessary; when performed, primary repair is usually possible. Despite resection in this population of patients with multiple and bilateral tumors, and despite close-margin and positive-margin resection in a significant proportion, recurrence on the portal vein or vena cava was not observed, and long-term survival is accomplished (41% 5-year overall survival).

Hepatic resection for noncolorectal nonendocrine liver metastases: analysis of 1,452 patients and development of a prognostic model

OBJECTIVE

To determine the utility of hepatic resection (HR) in the treatment of patients with noncolorectal nonendocrine liver metastases (NCNELM).

SUMMARY BACKGROUND DATA

The place of HR in the treatment of NCNELM remains controversial, primarily due to the limitations of previously published reports and the heterogeneity of primary tumor sites and histologies.

METHODS

A multivariate risk model was developed by analyzing prognostic factors and long-term outcomes in 1452 patients with NCNELM treated with HR at 41 centers from 1983 to 2004.

RESULTS

Hepatic metastases were solitary in 56% and unilateral in 71% (mean diameter, 50.5 mm). Extrahepatic metastases were present in 22%. The most common primary sites were breast (32%), gastrointestinal (16%), and urologic (14%). The most common histologies were adenocarcinoma (60%), GIST/sarcoma (13.5%), and melanoma (13%). R0 resection was achieved in 83% of patients with a 60-day mortality rate of 2.3% and a major complication rate of 21.5%. Tumor recurred in 67% of patients (liver, 24%; extrahepatic, 18%; both, 25%). Overall and disease-free survivals at 5 years were 36% and 21% and at 10 years were 23% and 15%, respectively. In multivariate analysis, factors associated with poor prognosis were patient age >60 years, nonbreast origin, melanoma or squamous histology, disease-free interval <12 months, extrahepatic metastases, R2 resection, and major hepatectomy (all P < or = 0.02). A prognostic model based on these factors effectively stratified patients into low-risk (0-3 points, 46% 5-year survival), mid-risk (4-6 points, 33% 5-year survival), and high-risk (>6 points, <10% 5-year survival) groups (P = 0.0001).

DISCUSSION

HR for NCNELM is safe and effective, with outcomes mainly dependent on primary tumor site and histology. For individual patients, a statistical model based on key prognostic factors could validate the indication for hepatic resection by predicting long-term survivals.

Importance of histological tumor response assessment in predicting the outcome in patients with colorectal liver metastases treated with neo-adjuvant chemotherapy followed by liver surgery

BACKGROUND

The purpose of the study was to characterize histological response to chemotherapy of hepatic colorectal metastases (HCRM), evaluate efficacy of different chemotherapies on histological response, and determine whether tumor regression grading (TRG) of HCRM predicts clinical outcome.

PATIENTS AND METHODS

TRG was evaluated on 525 HCRM surgically resected from 181 patients, 112 pretreated with chemotherapy. Disease-free survival (DFS) and overall survival (OS) were correlated to TRG.

RESULTS

Tumor regression was characterized by fibrosis overgrowing on tumor cells, decreased necrosis, and tumor glands (if present) at the periphery of HCRM. With irinotecan/5-fluorouracil (5-FU), major (MjHR), partial (PHR), and no (NHR) histological tumor regression were observed in 17%, 13%, and 70% of patients, respectively. With oxaliplatin/5-FU, MjHR, PHR, and NHR were observed in 37%, 45%, and 18% of patients, respectively. Five patients, treated with oxaliplatin, had complete response in all their metastases. MjHR was associated with an improved 3-year DFS compared with PHR or NHR. MjHR and PHR were associated with an improved 5-year OS compared with NHR.

CONCLUSION

Histological tumor regression of HCRM to chemotherapy corresponds to fibrosis overgrowth and not to increase of necrosis. TRG should be considered when evaluating efficacy of chemotherapy for HCRM. Histological tumor regression was most common among oxaliplatin-treated patients and associated with better clinical outcome.

Long-term renal function after liver transplantation is related to calcineurin inhibitors blood levels

BACKGROUND

Renal dysfunction is common after liver transplantation (LT). The aim of our study was to assess the prevalence of renal dysfunction 5 yr after LT and to identify risk factors for the development of this complication.

PATIENTS AND METHODS

A total of 134 adult patients underwent LT from 1987 to 1998 and 74.6% of them were alive 5 yr after. Pre-LT, 1 and 5 yr post-LT renal function were calculated by Cockroft and modification of diet in renal disease (MDRD) formula. Since 1987 glomerular filtration rate (GFR) has been measured by radiolabeled tracers clearance (RTC). Risk factors for GFR < 50 mL/min were analyzed using a multivariate logistic regression model.

RESULTS

Mean pre-LT GFR was 79 and 85 mL/min with Cockroft and MDRD respectively; 11% of the patients had a GFR <or= 50 mL/min. 5 yr after LT, mean GFR was 63, 61 and 70 mL/min with MDRD, Cockroft and RTC respectively, GFR decreased by 26%, and 25% of the patients had a GFR < 50 mL/min. Independent risk factors associated with impaired renal function were: trough levels of cyclosporin A (CyA) >or= 150 microg/L or tacrolimus (FK) >or= 10 microg/L at 1 yr and CyA >or= 100 microg/L or FK >or= 8 microg/L at 5 yr.

CONCLUSION

5 yr after LT, patients have lost 26% of their initial GFR and 25% of them have a GFR < 50 mL/min. This complication is predicted by high levels of calcineurin inhibitors (CNI). Therefore CNI levels should be reduced as low as possible and use of alternative drugs should be considered.

[Management of patients after liver transplantation]

The success of liver transplantation essentially depends on the prevention and treatment of long term complications, which may be due to surgery, opportunistic infections, organ rejection and relapse of the initial liver disease. The side effects of immunosuppressive drugs--arterial hypertension, glucose intolerance and diabetes, dyslipidemia and obesity, renal failure, osteoporosis, malignancy, and anaemia--should be regularly screened and treated without delay. Surgical procedures in transplanted patients are safe and rarely followed by complications. Although pregnancy in this setting is considered at risk, because of prematurity and low birth weight, overall outcomes are favourable. The yearly influenza vaccination is strongly recommended. The survival and the quality of life of liver transplant patients also depend on a good communication between the general practitioner and the transplantation centre.

Pamidronate and osteoporosis prevention in liver transplant recipients

Osteoporosis is a common complication in patients with end-stage liver disease and after orthotopic liver transplantation (LT), with resulting increasing fracture rate. In this study, we investigated the role of treatment with pamidronate in preventing further bone loss after LT. Eighty-five patients with end-stage liver disease were included in the study. Pamidronate 30 mg was given intravenously every 3 months after LT for the duration of 1 year to 43 patients with osteopenia or osteoporosis prior LT. The remainders served as controls. All patients received a supplementation of calcium and vitamin D. Bone mineral density (BMD) at the lumbar spine and the femoral neck, and markers of bone metabolism were measured before and 12 months after LT. Sixty-two BMD were available at 12 months; only paired BMD were evaluated. A significant increase in lumbar spine BMD was observed in pamidronate treated patients. No change was evident in controls. Femoral neck BMD decreased in both treated and untreated patients. Osteocalcin serum levels and deoxypyridinoline urinary excretion were significantly reduced by treatment. Our study suggests that pamidronate decreases bone turnover and is effective in preventing the course of bone loss after LT, however the efficacy, at the dosage regimen employed and in a follow-up of 12 months, appears to be limited to trabecular bone, with no effect on the cortical structure of the femur.

Perendoscopic variceal pressure measurement

OBJECTIVES

In patients with cirrhosis, the hepatic venous pressure gradient (HVPG) is the reference method for the assessment of portal hypertension (PHT). Variceal pressure (VP) may be measured at endoscopy, but its relationship to the HVPG remains controversial. The aim of the study was to retrospectively compare HVPG and VP values obtained in a cohort of patients with cirrhosis and PHT.

METHODS

Within 8 days (range: 6-10 days), 64 patients in a stable condition with biopsy-proven cirrhosis [alcoholic: 47; other 17; mean age: 56.5 yrs (35-70); mean Child-Pugh's score: 9.4 +/- 1.9; ascites: 37/64; previous variceal bleeding (="bleeders"): 24/64) and oesophageal varices (grade 2: 49; grade 3: 15)] underwent both measurement of the HVPG during transjugular liver biopsy and VP at endoscopy using a "home made" pressure sensitive gauge in the absence of needle puncture of the varix. Alcoholic hepatitis was present in 28 patients with alcoholic cirrhosis.

RESULTS

The pressure sensitive gauge was well tolerated. The mean HVPG and VP values were 18.5 +/- 3.4 mmHg and 19 +/- 3.7 mmHg, respectively. A significant difference was observed between "bleeders" (n=24) and non "bleeders" (n=40) in terms of VP values (21.4 +/- 3.3 vs 17.2 +/- 3.2 mmHg, P<0.001), but not for HVPG values (19.4 +/- 4.1 vs 17.9 +/- 2.8 mmHg, P=0.075). A positive correlation was observed between VP and HVPG values (r=0.62, P<0.0001).

CONCLUSIONS

In this group of patients with cirrhosis and oesophageal varices, a "home-made" pressure sensitive gauge allowed a non invasive perendoscopic measurement of VP. The positive correlation between VP and HVPG values suggests that measurement of VP may be a reliable estimate of portal pressure in these patients.

Cardiovascular collapse due to massive pulmonary thromboembolism during orthotopic liver transplantation

Severe pulmonary thromboembolism has been occasionally reported during orthotopic liver transplantation, with fatal outcomes occurring in about 50% of cases because of low cardiac output and multiple organ failure. Perioperative alterations in coagulation, insertion of pulmonary artery and other invasive catheters, administration of antifibrinolytic agents, and repeated ischemic insults may all promote the formation of intravascular/cardiac blood clots. We present a case of intraoperative right ventricular failure associated with the presence of a large thrombus wrapped around the pulmonary artery catheter. Identification of risk factors for intraoperative pulmonary thromboembolism warrants a prophylactic medical approach including selective blood component therapy and administration of antifibrinolytics guided by bedside coagulation tests as well as noninvasive hemodynamic monitoring.

Neoadjuvant chemotherapy and resection of advanced synchronous liver metastases before treatment of the colorectal primary

BACKGROUND

In many patients with advanced synchronous liver metastases from colorectal tumours, the metastases progress during treatment of the primary, precluding curative treatment. The authors have investigated a management strategy that involves high-impact chemotherapy first, resection of liver metastases second and finally removal of the primary tumour in patients with adverse prognostic factors.

METHODS

Twenty consecutive patients with non-obstructive colonic (nine patients) or rectal (11 patients) cancer and advanced synchronous liver metastases were treated according to this strategy. Median age was 56 years. Patients received between two and six cycles of 5-fluorouracil, oxaliplatin and irinotecan-based chemotherapy. Data were collected prospectively.

RESULTS

Overall survival rates at 1, 2, 3 and 4 years after the start of treatment were 85, 79, 71 and 56 per cent respectively, with a median survival of 46 months. Sixteen of the 20 patients had complete removal of liver metastases and colorectal tumours (resectability rate 80 per cent).

CONCLUSION

This new strategy produced resectability and survival rates better than those expected from the published data on patients with disease of similar severity. It allows initial control and downstaging of liver metastases, and delivery of preoperative radiotherapy for rectal cancer without the fear that liver metastases will meanwhile progress beyond the possibility of cure.

LiverMetSurvey: Analysis of clinicopathologic factors associated with the efficacy of preoperative chemotherapy in 2,122 patients with colorectal liver metastases

3521

Background: LiverMetSurvey is an international, internet-based registry designed to assess the efficacy of multimodality treatment options for colorectal liver metastases (CLM) by analyzing outcomes following hepatic resection (HR) in a large number of patients. Methods: Data were analyzed for the 2,122 patients entered into LiverMetSurvey by six hepatobiliary centers from inception to August 2004 (HR: 1974 to 2004; 1,306 men: 816 women; mean age: 61 years). The distributions of potential prognostic factors including age, sex, primary tumor site, timing of metastasis diagnosis, tumor number, diameter of the largest metastasis, bilaterality, and treatment with chemotherapy were compared to survivals using univariate and multivariate statistics. Results: Metastases originated in the colon in 69% of patients and were synchronous (diagnosed within 3 mo of primary tumor treatment) in 49% of patients. 34% of patients had ≥ 3 metastases and tumors were distributed bilaterally in 43% of cases. The mean size of the largest metastasis was 41.8 mm. 55% of patients were treated with preoperative systemic chemotherapy. Following resection, 60-day mortality was 1.2% and median, 5-year, and 10-year overall survivals (OS) were 46 mo, 42%, and 26%, respectively. Variables independently associated with poor prognosis included number of metastases > 3 (p<0.0001), bilateral metastases (p=0.0002), and size of the largest metastasis > 5 cm (p=0.03). Preoperative chemotherapy (PC) did not appear to benefit patients with solitary CLM (5-yr OS: PC 45% vs. no PC 58%), but was associated with improved survival in patients with > 5 metastases (5-yr OS: PC 22% vs. no PC 12%). Conclusions: Assessment of outcomes for the first 2,122 registrants to LiverMetSurvey not only confirms the prognostic importance of intrahepatic tumor burden, but also indicates that the ability of preoperative systemic chemotherapy to improve survivals is limited to patients with multiple (> 5) metastases. In addition, this analysis demonstrates the potential for LiverMetSurvey, which is now prospectively enrolling patients from over 40 centers, to determine the therapeutic value of current and future treatment strategies.

No significant financial relationships to disclose.

[When should cholecystectomy be practiced? Not always an easy decision]

Gallstone disease is a frequent medical problem. Cholelithiasis affects 10% of the population and 30% of patients with gallstones will undergo surgery. The treatment of choice for symptomatic gallstones remains cholecystectomy. A prophylactic cholecystectomy is indicated for asymptomatic patients in the presence of polyps, porcelain gallbladder or during bariatric surgery. The management of the complications of gallstone disease is discussed. At present, common bile duct stones, even if discovered preoperatively, should be managed by a multidisciplinary team including surgeons trained in laparoscopic techniques and gastroenterologists. This review is complemented by the information from a prospective database generated by a program called "DODIG" on 1099 cholecystectomies performed in our institution.

Hepatopulmonary syndrome increases the postoperative mortality rate following liver transplantation: a prospective study in 90 patients

Hepatopulmonary syndrome (HPS) is a frequent pulmonary complication of patients with end-stage liver diseases. HPS is diagnosed by hypoxemia and pulmonary vascular dilatation and is an independent risk factor of mortality. Orthotopic liver transplantation (OLT) is the only factor that modifies the natural course of HPS. Once patients with HPS have been transplanted, their long-term survival rate is similar to transplanted patients without HPS. Consequently, HPS is an indication of OLT whatever the severity of hypoxemia. However, besides the favorable long-term survival of HPS patients with OLT, a high postoperative mortality (mostly within 6 months) has been suggested. The aim of our study was to analyze the incidence of HPS and postoperative outcome after OLT in 90 consecutive patients. All patients were prospectively included and had blood gas analysis to detect HPS. Patients with hypoxemia had contrast echocardiography to confirm HPS. Nine patients had HPS with a 50 </= PaO(2)</= 70 mmHg. Among them 3 (33%) died while the mortality rate was 9.2% in the group without HPS (7 over 76 patients). In the HPS patients who survived, the syndrome completely recovered within 6 months. In conclusion, our study shows a high postoperative mortality rate following OLT even though the preoperative PaO(2) was >50 mmHg in all HPS patients transplanted.

Hepatocellular carcinoma in a liver-cell adenoma within a non-cirrhotic liver

Liver-cell adenomas are benign lesions of the liver occurring predominantly in young women. Hepatocellular carcinomas in most of the cases arise in a cirrhotic liver during the fifth or sixth decade. We describe the case of a 40-year-old woman in whom work-up for epigastric pain revealed a peptic ulcer and a large hepatic mass. Tests for chronic liver diseases were negative. Imaging findings and biopsy specimens of the tumour were inconclusive. The tumour was surgically removed and a hepatocellular carcinoma arising within a liver-cell adenoma in a non-cirrhotic liver was found. Malignant transformation of liver-cell adenoma has only been reported in a few case reports. Mechanisms of transformation remain unclear. The imaging findings as well as histological features are presented in detail and the literature is discussed.

Liver transplantation for Budd-Chiari syndrome: A European study on 248 patients from 51 centres

BACKGROUND/AIMS

The results of liver transplantation for Budd-Chiari syndrome (BCS) are poorly known and the role and timing of the procedure are still controversial. The aim of this study was to investigate the results of transplantation for BCS, focusing on overall outcome, on prognostic factors and on the impact of the underlying disease.

METHODS

An enquiry on 248 patients representing 84% of the patients transplanted for BCS in the European Liver Transplantation Registry between 1988 and 1999.

RESULTS

Of the 248 patients, 70.4% were female and 29.6% male. The mean age was 35.7 years. The overall actuarial survival was 76% at 1 year, 71% at 5 years and 68% at 10 years. 77% of deaths occurred in the first 3 months: 47% were due to infection and multiple organ failure, and 18% to graft failure or hepatic artery thrombosis. Late mortality (>1 year) occurred in nine patients, due to BCS recurrence in four of them. The only pre-transplant predictors of mortality on multivariate analysis (Cox) were impaired renal function and a history of a shunt.

CONCLUSIONS

Liver transplantation for BCS is an effective treatment, irrespective of the underlying cause, and should be considered before renal failure occurs.

In vivo microscopic examination of the esophagus for the detection of cancer before liver transplantation in patients with alcoholic cirrhosis

Esophageal squamous-cell carcinoma is relatively common in alcohol and tobacco abusers, and it can develop rapidly after liver transplantation. We report the early detection of an esophageal squamous-cell carcinoma in a patient with alcoholic cirrhosis, diagnosed during the pre-enlistment work-up that he was undergoing before liver transplantation. This lesion had not been detected at standard endoscopy, but was well characterized using in vivo staining and microscopic examination with an "endocytoscopy" system.

Infection and rejection in liver transplant patients: a 10-year Swiss single-centre experience

INTRODUCTION

Graft rejection and infection remain major morbidities following orthotopic liver transplantation (OLT). Rejection treatment may be associated with an increased rate of infectious complications. The aim of this study was to determine the relationship between rejection, rejection therapy and the risk of associated infections.

MATERIALS AND METHODS

A retrospective study of all adult patients undergoing OLT between July 1987 and July 1997 at a single university medical centre was carried out. Data for all transplant recipients were collected using predetermined definitions for infectious complications.

RESULTS

One hundred OLTs were performed on 98 patients (two patients received a second transplant). The cohort consisted of 33 women and 65 men with a mean age of 47 years. Seventy-eight patients developed a total of 228 infectious episodes: 107 bacterial, 101 viral, 17 fungal and 3 protozoan. The majority of infections occurred within the first month of OLT. Thirty patients without rejection developed 42 infectious episodes, whereas 70 patients with at least one treated rejection episode developed 186 infectious episodes. The overall rate of infection was 44.4 episodes per 1000 patient-days in the 30 days before rejection, and 94.4 episodes per 1000 patient-days in the 30 days following rejection treatment.

CONCLUSIONS

Infections occurred more frequently during the first month post-transplantation. Following OLT, rejection is associated with a higher incidence of infection, mainly of viral origin, concurrent with increased immunosuppressive therapy.

Comparison between hepatic wedge resection and anatomic resection for colorectal liver metastases

Some investigators have suggested that wedge resection (WR) confers a higher incidence of positive margins and an inferior survival compared with anatomic resection (AR) of colorectal liver metastases (CLM). We sought to investigate the margin status, pattern of recurrence, and overall survival of patients with CLM treated with WR or AR. We identified 253 consecutive patients, in a multi-institutional database from 1991 to 2004, who underwent either WR or AR. WR was defined as a nonanatomic resection of the CLM, and AR was defined as single or multiple resections of one or two contiguous Couinaud segments. Clinicopathologic factors were analyzed with regard to pattern of recurrence and survival. One hundred six WRs were performed in 72 patients and 194 ARs in 181 patients. There was no difference in the rate of positive surgical margin (8.3%), overall recurrence rates, or patterns of recurrence between patients treated with WR vs. AR. Patients who had a positive surgical resection margin were more likely to recur at the surgical margin regardless of whether they underwent WR or AR. The median survival was 76.6 months for WR and 80.8 months for AR, with 5-year actuarial survival rates of 61% and 60%, respectively. AR is not superior to WR in terms of tumor clearance, pattern of recurrence, or survival. WR should remain an integral component of the surgical treatment of CLM.

Treatment of fulminant liver failure by transplantation of microencapsulated primary or immortalized xenogeneic hepatocytes

BACKGROUND

The aim of this study was to evaluate in vitro and in vivo functions of isolated hepatocytes after immortalization, cryopreservation, encapsulation and xenotransplantation into mice with fulminant liver failure (FLF).

METHODS

Rat and human hepatocytes were isolated from normal liver tissue by collagenase digestion. Human hepatocytes were immortalized using lentiviral vectors coding for SV 40 large T antigen, Bmi-1 and telomerase. Rat and immortalized human hepatocytes (IHH) were encapsulated in 400 micron alginate-PLL-alginate membranes and cryopreserved using a computerized device. In vitro, encapsulated hepatocytes (cryopreserved or freshly isolated) were cultured in albumin-free medium and albumin production was measured by enzyme-linked immunosorbent assay (ELISA). In vivo, a model of FLF was established in C57/BL6 mice by acetaminophen administration (700 mg/kg i.p.) followed 15 h later by a 30% hepatectomy. Microencapsulated (cryopreserved or freshly isolated) hepatocytes were transplanted intraperitoneally to mice with FLF and the following experimental groups were performed: group 1 (n = 10) Tx of empty capsules; group 2 (n = 12) Tx of free primary rat hepatocytes; group 3 (n = 12) Tx of cryopreserved encapsulated rat hepatocytes; group 4 (n = 10) Tx of fresh encapsulated rat hepatocytes; group 5 (n = 9) Tx of cryopreserved encapsulated IHH; group 6 (n = 10) Tx of fresh encapsulated IHH. Animals were killed at regular intervals and histopathology of microcapsules and liver tissue was obtained.

RESULTS

In vitro, cryopreserved or fresh encapsulated rodent hepatocytes showed a progressively decreasing albumin secretion over 1 week in culture. In contrast, cryopreserved or fresh encapsulated IHH showed minimal, but stable albumin secretion. In vivo, FLF was achieved by combination of acetaminophen with 30% hepatectomy, resulting in a reproducible survival of 23% +/- 5%. In groups 1 and 2, survival rates were not improved significantly compared with untreated mice. In groups 3 and 4, Tx of cryopreserved or fresh encapsulated rat hepatocytes significantly increased survival rate to 66% and 80%, respectively (P < 0.01). In groups 5 and 6, Tx of cryopreserved or fresh encapsulated IHH improved survival to 50% and 55%, respectively (P < 0.05). Histopathology revealed that encapsulated hepatocytes were viable up to 2 weeks post-Tx.

CONCLUSIONS

Primary rodent hepatocytes maintained synthetic functions after encapsulation and cryopreservation short-term. IHH showed minimal albumin secretion in the absence of encapsulation and cryopreservation, suggesting that hepatocytes loose specific functions after immortalization. After induction of FLF in mice, intraperitoneal Tx of encapsulated (primary or immortalized, fresh or cryopreserved) xenogeneic hepatocytes significantly improved survival. These results indicate that naïve and genetically modified hepatocytes can successfully be encapsulated, stored using cryopreservation, and be transplanted into xenogeneic recipients with liver failure and sustain liver metabolic functions.

OncoSurge: a strategy for improving resectability with curative intent in metastatic colorectal cancer

PURPOSE

Most patients with colorectal liver metastases present to general surgeons and oncologists without a specialist interest in their management. Since treatment strategy is frequently dependent on the response to earlier treatments, our aim was to create a therapeutic decision model identifying appropriate procedure sequences.

METHODS

We used the RAND Corporation/University of California, Los Angeles Appropriateness Method (RAM) assessing strategies of resection, local ablation and chemotherapy. After a comprehensive literature review, an expert panel rated appropriateness of each treatment option for a total of 1,872 ratings decisions in 252 cases. A decision model was constructed, consensus measured and results validated using 48 virtual cases, and 34 real cases with known outcomes.

RESULTS

Consensus was achieved with overall agreement rates of 93.4 to 99.1%. Absolute resection contraindications included unresectable extrahepatic disease, more than 70% liver involvement, liver failure, and being surgically unfit. Factors not influencing treatment strategy were age, primary tumor stage, timing of metastases detection, past blood transfusion, liver resection type, pre-resection carcinoembryonic antigen (CEA), and previous hepatectomy. Immediate resection was appropriate with adequate radiologically-defined resection margins and no portal adenopathy; other factors included presence of < or = 4 or > 4 metastases and unilobar or bilobar involvement. Resection was appropriate postchemotherapy, independent of tumor response in the case of < or = 4 metastases and unilobar liver involvement. Resection was appropriate only for > 4 metastases or bilobar liver involvement, after tumor shrinkage with chemotherapy. When possible, resection was preferred to local ablation.

CONCLUSION

The results were incorporated into a decision matrix, creating a computer program (OncoSurge). This model identifies individual patient resectability, recommending optimal treatment strategies. It may also be used for medical education.

Treatment of fulminant liver failure by transplantation of microencapsulated primary or immortalized xenogeneic hepatocytes

BACKGROUND

The aim of this study was to evaluate the in vitro and in vivo function of hepatocytes after immortalization, cryopreservation, encapsulation, and xenotransplantation into mice with fulminant liver failure (FLF).

METHODS

Rat and human hepatocytes were isolated by collagenase digestion. Human hepatocytes were immortalized using lentiviral vectors. Rat and immortalized human hepatocytes (IHH) were encapsulated in 400 microm of alginate-poly-L-lysine (PLL; Sigma, Buchs, Switzerland)-alginate membranes and cryopreserved using a computerized device. In vitro, encapsulated hepatocytes (cryopreserved or noncryopreserved) were cultured; albumin secretion was measured by enzyme-linked immunosorbent assay. Microencapsulated (cryopreserved or noncryopreserved) hepatocytes were transplanted intraperitoneally to mice with FLF: group 1 (n = 10) transplantation of empty capsules; group 2 (n = 12) transplantation of free primary rat hepatocytes; group 3 (n = 12) transplantation of cryopreserved encapsulated rat hepatocytes; group 4 (n = 10) transplantation of encapsulated rat hepatocytes; group 5 (n = 9) transplantation of cryopreserved encapsulated IHH; group 6 (n = 10) transplantation of encapsulated IHH.

RESULTS

Compared with free primary hepatocytes, cryopreserved or noncryopreserved encapsulated rodent hepatocytes showed similar levels of continuous in vitro albumin secretion over 1 week. Cryopreserved or noncryopreserved encapsulated IHH showed minimal albumin secretion compared with free primary human hepatocytes. Fulminant liver failure, produced by a combination of acetaminophen and 30% hepatectomy, resulted in a 20% to 30% host survival. In groups 1 and 2, survival was unmodified, compared with untreated mice. For groups 3 and 4, transplantation of cryopreserved or noncryopreserved encapsulated rat hepatocytes significantly increased survival rates to 66% and 80%, respectively (P < .01). For groups 5 and 6, transplantation of cryopreserved or noncryopreserved encapsulated IHH improved host survival to 50% and 55%, respectively (P < .05).

CONCLUSIONS

Primary rodent hepatocytes maintained synthetic functions after encapsulation and cryopreservation. Immortalized human hepatocytes showed minimal albumin secretion in the absence of encapsulation and cryopreservation, suggesting that hepatocytes lose some specific functions after immortalization. After induction of FLF in mice, intraperitoneal transplantation of encapsulated (primary or immortalized, cryopreserved or noncryopreserved) xenogeneic hepatocytes significantly improved survival. These results indicate that naive and genetically modified hepatocytes can be successfully encapsulated, stored by cryopreservation, and transplanted into xenogeneic recipients with FLF to sustain liver metabolic functions.

Infection and rejection in liver transplant patients: a 10-year Swiss single-centre experience

INTRODUCTION

Graft rejection and infection remain major morbidities following orthotopic liver transplantation (OLT). Rejection treatment may be associated with an increased rate of infectious complications. The aim of this study was to determine the relationship between rejection, rejection therapy and the risk of associated infections.

MATERIALS AND METHODS

A retrospective study of all adult patients undergoing OLT between July 1987 and July 1997 at a single university medical centre was carried out. Data for all transplant recipients were collected using predetermined definitions for infectious complications.

RESULTS

One hundred OLTs were performed on 98 patients (two patients received a second transplant). The cohort consisted of 33 women and 65 men with a mean age of 47 years. Seventy-eight patients developed a total of 228 infectious episodes: 107 bacterial, 101 viral, 17 fungal and 3 protozoan. The majority of infections occurred within the first month of OLT. Thirty patients without rejection developed 42 infectious episodes, whereas 70 patients with at least one treated rejection episode developed 186 infectious episodes. The overall rate of infection was 44.4 episodes per 1000 patient-days in the 30 days before rejection, and 94.4 episodes per 1000 patient-days in the 30 days following rejection treatment.

CONCLUSIONS

Infections occurred more frequently during the first month post-transplantation. Following OLT, rejection is associated with a higher incidence of infection, mainly of viral origin, concurrent with increased immunosuppressive therapy.

Management of hepatocellular adenoma: Solitary-uncomplicated, multiple and ruptured tumors

AIM: While hepatocellular adenomas (HAs) have often been studied as a unique entity, we aimed to better define current management of the various forms of HAs.

METHODS: Twenty-five consecutive patients operated for solitary-uncomplicated (9), multiple (6), and ruptured (10) HAs were reviewed according to management strategies and outcomes.

RESULTS: All solitary-uncomplicated HAs (ranged 2.2-14 cm in size) were removed. Out of 25 HAs, 2 (8%) included foci of carcinoma. In the multiple HA group, previously undiagnosed tumors were identified during surgery in 5/6 cases. In three cases with multiple spread HA, several lesions had to be left unresected. They remained unmodified after 4-, 6-, and 6-year radiological follow-up. Patients with ruptured HA (ranged 1.7-10 cm in size) were initially managed with hemodynamic support and angiography, allowing the embolization of actively bleeding tumors in two patients. All ruptured tumors were subsequently removed 5.5 d (range 4-70 d) after admission.

CONCLUSION: Tumors suspected of HA, regardless of the size, should be resected, because of high chances of rupture causing bleeding, and/or containing malignant foci. Although it is desirable to remove all lesions of multiple HA, this may not be possible in some patients, for whom long-term radiological follow-up is advised. Ruptured HA can be managed by hemodynamic support and angiography, allowing scheduled surgery.

Impact of HLA matching on the outcome of simultaneous pancreas-kidney transplantation

BACKGROUND

Simultaneous pancreas-kidney (SPK) transplantation has become the therapy of choice for type 1 diabetic patients with end-stage renal disease. The current analysis examined the impact of human leukocyte antigen (HLA) matching on graft outcome following SPK transplantation. The study population was obtained from patients enrolled in the Euro-SPK 001 study.

METHODS

The effect of HLA matching on graft function and survival was assessed in 180 SPK recipients in whom complete donor-recipient HLA data were available. A group of 45 patients with 0-3 HLA mismatches (MM) was compared with a group of 135 patients with 4-6 MM.

RESULTS

There were no differences in 3-year kidney, pancreas or patient survival between the 0-3 and 4-6 MM groups. Biological parameters of kidney and pancreas graft function were similar in both groups. Significantly more patients with 0-3 MM (66%) were rejection-free at 3 years than was the case among those with 4-6 MM (41%; P = 0.003). The relative risk of acute rejection was 2.6 times higher among patients with 4-6 MM than among those with 0-3 MM.

CONCLUSIONS

There was no evidence that HLA matching was associated with improved kidney or pancreas survival. However, a higher rate of acute rejection was observed with poor HLA match, which may impact long-term survival.

Glomerular and tubular function following orthotopic liver transplantation in children

Since its advent, cyclosporine nephrotoxicity has been a major concern to pediatricians attending to liver transplant recipients. The aims of this study were to examine glomerular and tubular function after orthotopic liver transplantation (OLT) in children, their correlation to CsA, and how they differed according to the underlying disease.

PATIENTS AND METHODS

Glomerular and tubular function was examined in 28 patients aged 7 months to 14 yr at the time of transplantation (mean 4.0 +/- 3.6), retrospectively examining creatinine clearance, tubular phosphate reabsorption (TRP), calcium/creatinine ratio, sodium excretion fraction, and protein/creatinine ratio. The group with metabolic disease and an underlying tubulopathy was compared with the group with liver disease only. The effect of CsA trough levels and cumulated dose on these indices was examined, as was the effect of antihypertensives on creatinine clearance. Both glomerular and tubular functions improved significantly following liver transplantation. In patients on CsA (n = 21), CrCl decreased significantly at 1 month post-OLT (42.6 +/- 26.6 mL/min/1.73 m(2)) when compared with pretransplantation, and 3, 12 and 60 months post-OLT (p < 0.05). It improved between 12 and 60 months post-OLT (p < 0.05). It was correlated with cyclosporine trough levels (p < 0.03), and with total dose of CsA at 12 months. This was not true for patients on tacrolimus (n = 7). Overall pretransplant TRP was below normal (73.7% +/- 19.6), which was significantly lower than the values at years 2, 3, and 5 post-OLT (p < 0.05), owing mainly to the metabolic group which recovered normal proximal tubular function by the end of the second week post-OLT. Calcium/creatinine ratio was significantly worse in the group with liver disease only (p < 0.01). Protein/creatinine ratio normalized rapidly in both groups. Urinary sodium excretion fraction (FENa) was very abnormal in the early postoperative phase, normalizing thereafter in both groups. Kidney function improved after liver transplantation in patients with and without pre-existing kidney dysfunction. Overall, creatinine clearance was correlated to CsA trough levels suggesting CsA did not have an irreversible 'sclerosing' effect in the medium term. Combined antihypertensive therapy using nifedipine and enalapril may be the optimal choice for patients requiring medical management of their hypertension, although the observed effect on creatinine clearance did not reach statistical significance in this study. Tubular dysfunction is frequent in both groups of patients, pre- and post-transplant, and may contribute to bone mineral density as well as to metabolic disturbances in this population.

Effect of HLA Matching in Simultaneous Pancreas–Kidney Transplantation

Simultaneous pancreas-kidney (SPK) transplantation has become the therapy of choice for type 1 diabetic patients with end-stage renal disease. The current analysis examined the impact of HLA matching on graft outcome following SPK transplantation. The study population was obtained from patients enrolled in the Euro-SPK 001 study.

PATIENTS AND METHODS

The effect of HLA matching on graft function and survival was assessed in 180 SPK recipients in whom complete donor-recipient HLA data were available. A group of 45 patients with 0 to 3 HLA mismatches (MM) was compared to 135 patients with 4 to 6 MM.

RESULTS

There were no differences in 3-year kidney, pancreas, or patient survival rates between the 0 to 3 and 4 to 6 MM groups. Biological parameters of kidney and pancreas graft function were similar in both groups. Significantly more patients with 0 to 3 MM (66%) were rejection free at 3 years than those with 4 to 6 MM (41%; P = .003). The relative risk of acute rejection was 2.6 times higher among patients with 4 to 6 MM than among those with 0 to 3 MM. In conclusion, there was no evidence that HLA matching was associated with improved kidney or pancreas survival. However, a higher rate of acute rejection was observed with poor HLA matches, which may impact long-term survival.

Oxaliplatin combined with irinotecan and 5-fluorouracil/leucovorin (OCFL) in metastatic colorectal cancer: a phase I–II study

BACKGROUND

A phase I-II multicenter trial was conducted to define the maximal tolerated dose and describe the activity of an OCFL combination using oxaliplatin (OHP), irinotecan (CPT-11) and 5-fluorouracil (FU)/leucovorin (LV) in metastatic colorectal cancer (CRC).

PATIENTS AND METHODS

CRC patients not pretreated with palliative chemotherapy, with performance status < or =1 and adequate haematological, kidney and liver function, were eligible. Treatment consisted in weekly 24-h infusion 5-FU (2300 mg/m(2))/LV (30 mg) and alternating OHP (70-85 mg/m(2), days 1 and 15) and CPT-11 (80-140 mg/m(2), days 8 and 22) repeated every 5 weeks. OHP and CPT-11 were escalated in cohorts of three to six patients.

RESULTS

Thirty patients received a median of five cycles. Dose-limiting toxicity occurred at dose level 3, and the recommended dose was OHP 70 mg/m(2), CPT-11 100 mg/m(2), LV 30 mg and 5-FU 2300 mg/m(2)/24 h. Grade > or =3 toxicities were diarrhea 23%, neutropenia 20%, fatigue 7%, and neurologic 7%. Two febrile neutropenia episodes (one fatal) were recorded. Among 28 patients with measurable disease (90%), we observed two complete and 20 partial responses; overall RR was 78% (95% CI, 59% to 92%). Median time to progression and overall survival were 9.5 and 25.4 months, respectively. Seven patients underwent liver metastases resection.

CONCLUSION

OCFL is an overall well tolerated regimen with very high efficacy, which makes it most suitable for tumour control before surgery of metastatic disease.

Effect of surgical margin status on survival and site of recurrence after hepatic resection for colorectal metastases

OBJECTIVE

To evaluate the influence of surgical margin status on survival and site of recurrence in patients treated with hepatic resection for colorectal metastases.

METHODS

Using a multicenter database, 557 patients who underwent hepatic resection for colorectal metastases were identified. Demographics, operative data, pathologic margin status, site of recurrence (margin, other intrahepatic site, extrahepatic), and long-term survival data were collected and analyzed.

RESULTS

On final pathologic analysis, margin status was positive in 45 patients, and negative by 1 to 4 mm in 129, 5 to 9 mm in 85, and > or =1 cm in 298. At a median follow-up of 29 months, the 1-, 3-, and 5-year actuarial survival rates were 97%, 74%, and 58%; median survival was 74 months. Tumor size > or =5 cm, >3 tumor nodules, and carcinoembryonic antigen level >200 ng/mL predicted poor survival (all P < 0.05). Median survival was 49 months in patients with positive margins and not yet reached in patients with negative margins (P = 0.01). After hepatic resection, 225 (40.4%) patients had recurrence: 21 at the surgical margin, 56 at another intrahepatic site, 82 at an extrahepatic site, and 66 at both intrahepatic and extrahepatic sites. Patients with negative margins of 1 to 4 mm, 5 to 9 mm, and > or =1 cm had similar overall recurrence rates (P > 0.05). Patients with positive margins were more likely to have surgical margin recurrence (P = 0.003). Adverse preoperative biologic factors including tumor number greater than 3 (P = 0.01) and a preoperative CEA level greater than 200 ng/mL (P = 0.04) were associated with an increased risk of positive surgical margin.

CONCLUSIONS

A positive margin after resection of hepatic colorectal metastases is associated with adverse biologic factors and increased risk of surgical-margin recurrence. The width of a negative surgical margin does not affect survival, recurrence risk, or site of recurrence. A predicted margin of <1 cm after resection of hepatic colorectal metastases should not be used as an exclusion criterion for resection.

Surgical management and long-term outcome of complicated liver hydatid cysts caused by Echinococcus granulosus

BACKGROUND

The aim of this retrospective study was to evaluate clinical presentation and long-term outcome of patients treated surgically for complicated liver hydatid cysts.

PATIENTS AND METHODS

Eighty-four patients with liver hydatid cysts underwent an operation at the Geneva University Hospital between 1980 and 1999. Clinical presentation, postoperative morbidity, mortality, and long-term recurrence rate were evaluated.

RESULTS

Among the 84 patients with liver hydatid disease, 35 patients (41%) presented complicated cysts (ie, cysts that had developed a fistula into adjacent structures or organs). In most patients, the fistula communicated with the biliary tree (n = 25), but we also observed communication with the right lung (n = 3), the right diaphragm (n = 2), liver parenchyma (n = 1), and peritoneal cavity (n = 1). Complete removal of the cystic disease was possible in 24 of 35 patients (70%). In 11 patients, fragments of cysts were not removed because of their location adjacent to main vessels. Postoperatively, 8 patients (23%) developed a severe complication (grade II and III). There were no postoperative deaths, and no recurrences of hydatid disease were observed with a median follow-up of 8.6 years (complete follow-up was obtained in 69% of patients).

CONCLUSIONS

Complicated liver hydatid disease is frequent and was observed in almost half of patients operated for liver hydatid cysts at our center. Using a surgical strategy aimed at complete removal of cystic and pericystic tissue with simultaneous treatment of the fistulous tract, we observed 23% postoperative morbidity, no mortality, and no recurrence of disease with a median follow-up of >8 years.

Microchimerism after liver transplantation: absence of rejection without abrogation of anti-donor cytotoxic T-lymphocyte-mediated alloreactivity

Microchimerism (MC) is defined by the persistence of <1% circulating donor cells resulting from cell migration from the graft; MC may play a role in the induction of unresponsiveness to allogeneic tissues, or may be merely the consequence of the graft's acceptance following immunosuppression. To analyze early MC (7 patients) and late MC (12 patients) following a liver transplantation, we designed a sensitive and semiquantitative nested polymerase chain reaction (PCR) protocol based on the detection of incompatible human leukocyte antigen (HLA)-DRB1 donor alleles. MC was measured in multiple PCR samples and expressed as percent positive PCRs / time point. The detection level was 1 donor cell / 10(5) patient cells. All patients had detectable early MC, ranging from 5 to 100% positive PCRs in the 1st 3 months after transplantation. The kinetic analysis demonstrated that MC decreased during the 1st year in 6 of 7 patients. All of the 4 patients with the lowest MC had rejection episodes, vs. none among the 3 patients with MC >50%. However, cytotoxic T-lymphocyte reactivity (CTL) against HLA class I donor antigens could be demonstrated 1 year posttransplant in 2 patients with a high level of early MC. MC is a dynamic process, which is easily detectable <3 months after liver transplantation. In conclusion, a correlation between the level of early MC and the absence of rejection episodes was observed. However, high levels of early MC did not abrogate the persistence of an alloreactive response measured in vitro 1 year after transplantation, which suggests that MC did not lead to clonal deletion of donor-specific CTL.

Blunt Abdominal Trauma:Does the Use of a Second-Generation Sonographic Contrast Agent Help to Detect Solid Organ Injuries?

OBJECTIVE

The objective of our study was to prospectively evaluate whether a second-generation sonography contrast agent (SonoVue) can improve the conspicuity of solid organ injuries (liver; spleen; or kidney, including adrenal glands) in patients with blunt abdominal trauma.

SUBJECTS AND METHODS

Two hundred ten consecutive hemodynamically stable trauma patients underwent both abdominal sonography and CT at admission. The presence of solid organ injuries and the quality of sonography examinations were recorded. Patients with false-negative sonography findings for solid organ injuries in comparison with CT results underwent control sonography. If a solid organ injury was still undetectable, contrast-enhanced sonography was performed. Findings of admission, control, and contrast-enhanced sonograms were compared with CT results for their ability to depict solid organ injuries. Contrast-enhanced sonography was also performed in patients in whom a vascular injury (pseudoaneurysm) was shown on admission or control CT.

RESULTS

CT findings were positive for 88 solid organ injuries in 71 (34%) of the 210 patients. Admission, control, and contrast-enhanced sonograms had a detection rate for solid organ injury of 40% (35/88), 57% (50/88), and 80% (70/88), respectively. The improvement in the detection rate between control and contrast-enhanced sonography was statistically significant (p = 0.001). After exclusion of low-quality examinations, contrast-enhanced sonography still missed 18% of solid organ injuries. Five vascular liver (n = 1) and spleen (n = 4) injuries (pseudoaneurysms) were detected on CT; all were visible on contrast-enhanced sonography.

CONCLUSION

Contrast-enhanced sonography misses a large percentage of solid organ injuries and cannot be recommended to replace CT in the triage of hemodynamically stable trauma patients. However, contrast-enhanced sonography could play a role in the detection of pseudoaneurysms.

[Long-term followup of patients with alveolar echinococcosis]

INTRODUCTION

Alveolar Echinicoccosis is a severe parasitic disease: its natural evolution is comparable to a slowly progressive malignant liver tumour. There is no definitive medical therapy. Surgery remains the only option to assure a cure. This report is our surgical experience for the care of this affection.

PATIENTS AND METHOD

Between 1980 and 2002, 12 patients were operated for an hepatic alveolar echinococcosis. For 11 of them, the affection was primary. Lesions were located in the right liver lobe (n = 9), in the left lobe (n = 1), in both lobes (n = 1) and close to the hilar region (n = 1). Twice there was a diaphragmatic infiltration and once a pleural infiltration. Resections consisted in: segmentectomies in the right lobe (n = 4), right hepatectomy (n = 5, associated once with a partial I and IV segmentectomy), left hepatectomy (n = 1), one liver transplantation (n = 1), one drainage of a parasitic cavity (n = 1). One pleurectomy and a partial diaphragmatic resection were made. All patients were treated postoperatively with benzimidazole chemotherapy.

RESULTS

Three patients presented some complications: segmental necrosis with biloma (n = 1), biliary fistula tract (n = 1), subdiaphragmatic hematoma (n = 1), cholangitis (n = 1). 10 patients are alive (median follow-up of 10 years). Two patients still present some parasitic lesions; the situation remains doubtful for one of them. Two patients died (one of them in the context of a disease progression).

CONCLUSION

Surgical treatment, associated with medical therapy, assured a control of the parasitic lesions or a definitive cure in most cases. When the disease is limited to the liver with no possibility for partial hepatectomy, a transplantation is an option.