Increased levels of soluble complement receptor 1 in serum patients with liver diseases

Complement receptor type 1 (CR1) is an integral membrane protein of many hematopoietic cells and is found in a soluble form in plasma. Preliminary data have indicated that soluble complement receptor 1 (sCR1) levels in serum were increased in patients with cirrhosis. In this study, sCR1 was measured in patients with various liver diseases with a newly established enzyme-linked immunosorbent assay (ELISA). sCR1 level was elevated in chronic active hepatitis C (24 patients, 62.6 +/- 31 ng/ML; 31 normal controls, 31.4 +/- 7.8 ng/mL, P < .001), and in cirrhosis (35 patients, 143.7 +/- 61 ng/mL, P < .001). The levels increased transiently in 3 patients who had amanita phalloides intoxication. In 25 patients with advanced cirrhosis (pretransplantation screening), there were significant inverse correlations between sCR1 and both the prothrombin index (rs = -.60, P < .002) and the aminopyrine breath test (rs = -.51, P < .01). Following liver transplantation, the levels dropped from 166 +/- 70 to 49 +/- 24 ng/mL (P < .0001), and serial measurements in the posttransplantation period showed a correlation with liver dysfunction, regardless of etiology. Since CR1 is not produced by hepatocytes, the most likely explanation for the increased level of sCR1 is reduced is reduced catabolism. Thus, sCR1 may be added to the short list of large glycoproteins that accumulate in liver disease.

Auxiliary liver transplantation: regeneration of the native liver and outcome in 30 patients with fulminant hepatic failure--a multicenter European study

Auxiliary liver transplantation (LT) is a special procedure of LT which could be proposed to patients with fulminant hepatic failure (FHF) and has for aim that complete regeneration of the native liver (NL) left in place will allow the graft recipient to resume normal liver function after allograft withdrawal. We report 30 cases of auxiliary LT performed for FHF in 12 European centers. Twenty-five of 30 patients were younger than 50 years. The cause of FHF was hepatitis A virus (HAV) in 4 patients, hepatitis B virus (HBV) in 7, paracetamol overdose in 5, ecstasy in 2, hepatotoxic drugs in 4, autoimmune hepatitis in 2, liver lesions of preeclampsia in 1 and unknown in 5. A postoperative, both clinical and histological follow-up of more than 3 weeks was obtained in 22 patients, enabling us to look for indicators predictive of NL regeneration and outcome. Histological changes observed in the NL included complete regeneration in 68%, incomplete regeneration with obvious fibrous sequelae in 14% and severe liver fibrosis or cirrhosis in 18%, of the 22 patients studied. The percentage and distribution of necrosis observed in tissue samples of the NL at the time of transplantation was not related to the final outcome. Complete NL regeneration was observed in 15 patients, out of whom 14 were younger than 40 years. Patients with complete regeneration were mainly affected by FHF due to HAV, HBV, or paracetamol overdose. After a follow-up of 18/11 (mean/median) months (range, 3 to 67 months), 19 of the 30 patients (63%) survived and 13 of them (68%), i.e., 43% of the 30 patients, had resumed normal NL function, with interrupted immunosuppression, the ultimate goal of emergency auxiliary LT. We conclude that, in patients with FHF, auxiliary LT is a procedure feasible in a number of centers and is associated with a complete regeneration capability of the NL in a majority of survivors, especially in those younger than 40 years. Confirmation of these encouraging preliminary results by large-scale prospective studies is required.

Operative injury to the hepatic artery. Consequences of a biliary-enteric anastomosis and principles for rational management

Although the interruption of the hepatic arterial flow usually is well tolerated, this is not always the case, and it is important to predict in which circumstances complications are likely to occur. The main determinants that should guide the surgeon confronted with this problem are (1) whether the portal circulation is normal, (2) whether structures carrying collateral blood supply have been interrupted, and (3) whether some form of biliary reconstruction is needed. We present our experience with three patients in whom the hepatic artery was damaged at operation as examples of how this injury can be dealt with in practice and discuss the measures to prevent or treat the complications that developed.

Combined islet-lung transplantation in a cystic fibrosis patient

The prevalence of insulin-dependent diabetes mellitus (IDDM) in cystic fibrosis patients ranges from 2 to 8% and glucose intolerance up to 15%. In recent years, lung transplantation has helped to prolong life expectancy of cystic fibrosis patients and represents 10 to 30% of all indications for lung transplantation. The postoperative need for immunosuppressive therapy using diabetogenic agents has decompensatory effects on glucose regulation and will probably increase the number of insulin-dependent cystic fibrosis patients. We report the case of an insulin-dependent cystic fibrosis patient transplanted with a combined islet-lung allograft. The pre-transplantation C-peptide level was below 0.04 nmol/l and preoperative insulin requirement was some 100 U per day. A sequential bipulmonary lung transplantation was performed and, using the pancreas of the same donor, we isolated and purified the islets of Langerhans by a modified automated method. We obtained 232,200 islets equivalent, which were injected into the liver by portal embolization. The postoperative course was uncomplicated, the insulin requirement decreased to 50% of the preoperative need and the C-peptide value increased to normal values and remained with the normal range during a follow-up period of 15 months. In conclusion, we believe that, besides type I diabetic patients, insulin-dependent cystic fibrosis patients with a negative C-peptide value could also be good candidates for combined islet-lung allotransplantation.

[Efficacy of organ exchange rules in a 7 million population nation]

The suitability of organ exchange rules were analysed retrospectively in a country with a population of 7 million not connected to international organ sharing organisations following the opening of a national coordination centre 2 years previously. The results demonstrate that the sharing rules work frictionless and efficiently, and that compulsory registration of every organ donor (cadaveric and living) guarantees entire transparency of organ source and exchange, therefore preventing any illegal activity. An unacceptably high mortality rate for patients awaiting a highly urgent organ (specifically heart or liver) shows that connection to an international organ exchange organisation is desirable in this respect.

Duplicated hepatic artery: radiologic and surgical implications

Preoperative angiography of the coeliac trunk and superior mesenteric artery is routinely performed before liver resections and transplantations. For this purpose, it is usual to inject each branch of the coeliac trunk separately. Selective angiographic studies, however, may lead to overlooking surgically essential anatomic variations of the hepatic blood supply, as demonstrated by the present report. A case of a duplicated hepatic artery is presented, its radiologic and surgical implications discussed, and the relevant literature reviewed. This uncommon and particularly evocative feature illustrates the clinical importance of a sound knowledge of anatomical variants.

Systemic and splanchnic oxygen supply-demand relationship with fenoldopam, dopamine and noradrenaline in sheep

The effects of intravenous administration of fenoldopam (0.3-10 micrograms.kg-1.min-1), dopamine (1-10 micrograms.kg-1.min-1) and noradrenaline (0.1-1 micrograms.kg-1.min-1) on systemic and splanchnic haemodynamics and oxygen supply-demand relationship were studied in 12 chronically instrumented, sedated sheep. Fenoldopam produced dose-dependent peripheral and splanchnic vasodilatation without change in arterial blood pressure. The coeliac trunk and portal vein blood flows were particularly sensitive to fenoldopam, whereas dopamine vasodilated these vascular beds only at high doses. Renal blood flow was not influenced by dopamine or fenoldopam, but decreased by noradrenaline. Fenoldopam maintained systemic oxygen extraction constant by increasing both oxygen supply and demand, while noradrenaline and dopamine increased oxygen supply more than demand, thus decreasing oxygen extraction. Both dopamine and fenoldopam increased oxygen delivery to the splanchnic organs while noradrenaline reduced it. Splanchnic oxygen consumption decreased with noradrenaline and increased with dopamine, resulting in a conserved oxygen extraction with both drugs, whereas oxygen consumption remained constant at all doses of fenoldopam infusion (i.e. dose-dependent decreased oxygen extraction). Both noradrenaline and fenoldopam, but not dopamine, were accompanied by increased portal lactataemia. We conclude that in sheep fenoldopam is a potent and selective splanchnic vasodilator but without vasodilatator effect on the renal circulation. The portal lactataemia associated with a decreased splanchnic oxygen extraction may present a significant limitation for some clinical applications of this drug.

Orthotopic liver transplantation in hemophilia B: a case report

Liver transplantation is a treatment modality that is being used with increasing frequency in cases of liver-based metabolic defects. This is a case report of a patient with hemophilia B who was treated since childhood with factor IX replacement for recurrent hemarthroses. Subsequent hepatitis B (HBV) and C (HCV) infection had resulted in the development of chronic active hepatitis, ultimately leading to cirrhosis. Orthotopic liver transplantation performed for endstage liver disease resulted in a rise in factor IX levels from 2% to 83% of normal values within 24 h postoperatively, and levels remained above 90% of normal values after postoperative day 3 without factor IX replacement. To our knowledge, only two cases of hemophilia B treated by orthotopic liver transplantation have been reported. This procedure has, however, only been implemented in cases of terminal liver insufficiency in hemophiliacs.

[Risk in major hepatectomy. A consecutive series of 113 extensive hepatectomies]

Up to now, liver resections have been the initial treatment of almost all cancers and benign tumors limited to a liver lobe. This retrospective review assesses the results of a consecutive series of 113 major elective hepatic resections during a ten-year period. Major hepatectomy was defined by the resection of at least 3 Couinaud segments. Mean age was 52 years (20 to 79 years). There were 62 women and 51 men. 35 resections were performed for colorectal metastases, 22 for a benign tumor, 20 for non-colorectal metastases, 11 for hydatid disease, 10 for hepatocarcinoma, 7 for cholangiocarcinoma and 8 for other indications. The resections performed were 86 right hepatectomies with 18 extended right hepatectomies, 24 left hepatectomies with 4 extended left hepatectomies and 3 trisegmentectomies. Total vascular exclusion was used in 22 patients (19%). Mortality rate was zero. Significant morbidity was encountered in 24 patients (21%). These results suggest that the mortality rate may be independent of the extent of liver resection, provided that hepatic function is normal and preoperative selection adequate. With improving surgical management and techniques, and the use of intra-operative sonography, extensive liver surgery can now be performed with a very low mortality rate.

[Recurrence of diabetic disease following pancreas transplantation]

Type-I diabetes is considered an autoimmune disease, directed against pancreatic beta cells. Diabetes recurrence after pancreas transplantation is theoretically possible, and some cases have been reported after isotransplantation of segmental grafts in HLA-identical twins, where no rejection phenomenon is possible and where no immunosuppression was used. Diabetes recurrence has never been observed in a cadaveric allograft recipient, probably because immunosuppression efficiently blocks the autoimmune mechanism. Autoreactivity against beta cells exists life-long in type-I diabetes, and the immunosuppression used after transplantation becomes an advantage y preventing the recurrence of the disease.

Soluble interleukin-6 receptor strongly increases the production of acute-phase protein by hepatoma cells but exerts minimal changes on human primary hepatocytes

Interleukin-6 (IL-6) interacts with a system of receptors, which include a 80-kDa IL-6-binding subunit (IL-6R) and a transducing element (gp130). The soluble form of IL-6R (sIL-6R) can bind its ligand and induce cellular responses by association with gp130, thus acting as an IL-6 agonist. We and others have previously shown that the responsiveness to IL-6 is different in hepatoma and human primary hepatocytes. We therefore compared the effects of sIL-6R on the two types of cells, and on the B9 hybridoma, another IL-6-sensitive cell line. Human primary hepatocytes, hepatoma cells PLC/PRF/5, and B9 cells were incubated with different concentrations of IL-6, sIL-6-R, or both. The hepatocyte culture supernatants were tested for their content of acute-phase proteins (APP). The proliferation of B9 cells was assessed by a colorimetric method. Results showed that sIL-6R alone markedly increased the production of APP by hepatoma cells in a dose-dependent manner, but affects only minimally primary hepatocytes and the proliferation of B9 cells. The combinations of IL-6R and its ligand enhanced the effects of Il-6 alone in both PLC/PRF/5 and B9 cells, but had no effect on primary hepatocytes. An immunohistochemical study indicated that the cell-surface expression of IL-6R was dramatically lower in hepatoma cells than in primary hepatocytes. In conclusion, our results show that the expression of IL-6R is low in the hepatoma cell PLC/PRF/5 when compared with primary hepatocytes and that this difference can, at least partly, explain their deficient responsiveness to IL-6. On the other hand, it appears that IL-6R expression by primary hepatocytes is sufficient and that circulating sIL-6R is unlikely to play a significant role in the modulation of IL6 effects.

Magnetic resonance imaging with superparamagnetic iron oxide particles to evaluate hepatic macrophage-monocytic phagocytosis after arterial devascularization in minipigs

RATIONALE AND OBJECTIVES

We examined the effects of arterial ischemia on the phagocytic activity of the hepatic macrophage-monocytic phagocytic system (MMPS).

METHODS

Six minipigs were studied before and 24 hr after complete arterial devascularization of the liver. Magnetic resonance (MR) imaging was performed at 1.5 T using superparamagnetic iron oxide (SPIO) particles (18 mumol Fe/kg body weight) as an MMPS-specific contrast agent. Hepatobiliary scintigraphy, measurements of serum liver enzymes, and histology also were obtained.

RESULTS

On MR imaging, the postcontrast-to-precontrast ratios of the arterially devascularized livers were significantly higher than the corresponding baseline values (p < .01). The greatest difference (52%) between the baseline and the postoperative values was observed on gradient-echo (GE) images. Scintigraphy, laboratory analyses, and histology results indicate that the MR imaging findings were probably predominantly attributable to a reduction in phagocytic activity of the hepatic MMPS.

CONCLUSION

SPIO particles have already proved useful for improving detection of liver neoplasms on MR imaging, but they also may provide a novel way of evaluating the function of the hepatic MMPS in liver diseases.

MRI findings in Caroli's disease and intrahepatic pigmented calculi

This paper reports a case of Caroli's disease confined to the left lobe of the liver that mimicked left portal vein thrombosis on MRI studies because of the very high signal intensity on T1-weighted images of intrahepatic pigmented calculi. The preoperative diagnosis was a cholangiocarcinoma infiltrating the left hepatic bile duct and portal branch. The final macroscopic and histological diagnosis was Caroli's disease of the left liver lobe with wide enlarged left bile duct containing multiple pigmented calculi.

Glucokinase and cytosolic phosphoenolpyruvate carboxykinase (GTP) in the human liver. Regulation of gene expression in cultured hepatocytes

Glucokinase and phosphoenolpyruvate carboxykinase are key enzymes of glucose metabolism in the rat liver. The former is considered to be instrumental in regulating glucose hepatic release/uptake according to the glycaemia level, and cytosolic phosphoenolpyruvate carboxykinase is a major flux-generating enzyme for gluconeogenesis. The level of expression of both enzymes and the regulation of their mRNAs in the human liver cell were investigated. Surgical biopsies of liver from patients undergoing partial hepatectomies and parenchymal hepatocytes derived from the biopsies were used to assay glucokinase, hexokinase and phosphoenolpyruvate carboxykinase activities. Hepatocytes were placed in culture and the actions of insulin, glucagon and cAMP on glucokinase and phosphoenolpyruvate carboxykinase mRNAs were studied. The main results are: (a) glucokinase accounts for 95% of the glucose phosphorylation activity of human hepatocytes, although this fact is masked in assays of total liver tissue; (b) glucokinase activity is set at a lower level in human hepatocytes than in rat hepatocytes, and vice-versa for the gluconeogenic enzyme phosphoenolpyruvate carboxykinase; and (c) as previously shown in rat liver, glucokinase and phosphoenolpyruvate carboxykinase mRNAs are regulated in a reciprocal fashion in human hepatocytes, insulin inducing the first enzyme and repressing the latter, whereas glucagon has opposite effects. These data have interesting implications with respect to metabolic regulation and intracellular hormone signaling in the human liver.

IL-1 receptor antagonist (IL-1Ra) does not inhibit the production of C-reactive protein or serum amyloid A protein by human primary hepatocytes. Differential regulation in normal and tumour cells

The synthesis of some class 1 acute-phase proteins (APP), including C-reactive protein (CRP) and serum amyloid A (SAA) protein is completely blocked by the IL-1 receptor antagonist (IL-1Ra), whereas the production of fibrinogen, a class 2 APP, is increased by IL-1Ra in hepatoma cells, but this has never been tested in human hepatocytes in primary culture. Since previous studies on the contributions of cytokine inhibitors in connective tissues diseases suggested that IL-1 and tumour necrosis factor-alpha (TNF-alpha) might play an important role in the regulation of CRP, we decided to examine in more detail the respective roles of IL-1 beta, IL-6, and TNF-alpha and their inhibitors in the production of APP by human primary hepatocytes versus the hepatoma cell line PLC/PRF/5. In the hepatoma cell line, IL-1 beta and/or TNF-alpha had synergistic effects with IL-6 on the production of CRP and SAA. In contrast, these cytokines were devoid of effect in normal hepatocytes. The production of fibrinogen was increased by IL-6 and decreased by IL-1 (and TNF-alpha) in both cell types. The secretion of CRP and SAA by primary hepatocytes incubated with a cytokine-rich mononuclear cell-conditioned medium was totally unaffected by IL-1Ra or anti-TNF-alpha antibodies. In contrast, the addition of IL-1Ra increased the production of fibrinogen by both hepatoma cells and primary hepatocytes incubated with the mononuclear cell-conditioned medium. We therefore conclude that IL-1 beta and TNF-alpha do not exert any significant effect on the synthesis of CRP and SAA by human primary hepatocytes.

Surgery for adult polycystic liver disease

BACKGROUND

Occasionally patients with adult polycystic liver disease (APLD) have symptoms. For these patients surgery may represent a valuable therapeutic option to relieve symptoms.

METHODS

From September 1977 to August 1993 at our institution, 10 women with APLD were examined and surgically treated. They underwent a partial hepatic resection together with cyst fenestration. The surgical outcome and long-term follow-up were retrospectively analyzed.

RESULTS

Postoperative morbidity consisted of one case of pneumonia, and one case of acute pancreatitis with deep vein leg thrombosis. One patient died after acute Budd-Chiari syndrome developed as a result of liver collapse after fenestration of a posterior cyst. In the long term six of nine patients were symptom free. Late surgical complications included acute cholecystitis (one patient), small bowel obstruction (one), and incisional hernia (two).

CONCLUSIONS

A combined surgical approach of hepatic resection and cyst fenestration has proved feasible for patients with highly symptomatic APLD. Extensive fenestration of posterior cysts should be avoided; transverse hepatic resection (frontal hepatectomy) up to the costal margin is proposed. This therapy provides good results at long-term follow-up.

Niemann-Pick disease type C: nodular splenomegaly

Niemann-Pick type C disease (NPCD) is an autosomal recessive storage lipidosis due to a disorder of cholesterol esterification leading to the accumulation of sphingomyelin and cholesterol in the brain, liver, and spleen. The disease is usually diagnosed when neurological symptoms appear. We report an unusual presentation of NPCD in a young asymptomatic adult with isolated nodular splenomegaly.

[Mechanism of rejection of islet of Langerhans xenografts]

For immediately vascularised xenografts, the presence of preformed antibodies associated with the activation of the complement induces a hyperacute humoral rejection in discordant combinations. For neovascularised xenografts, such as the islets of Langerhans, the absence of an initial vascularisation prevents the acute humoral rejection and there is some evidence to suggest that the rejection is cell mediated. To analyse the influence of species response to cellular transplantation, we compared the functional outcome and the immunohistochemical analysis of concordant and discordant xenotransplated islets with allotransplanted islets of Langerhans. In the concordant xenotransplantation experiment, rat (Sprague Dawley) purified islets (N = 600) were transplanted under the kidney capsule of streptozotocin diabetic mice. In the discordant experiment, purified human islets (N = 1000), in the allotransplantation model Balb mouse islets (N = 600) were transplanted under the kidney capsule of C57BL/6 mice. Daily blood glucose levels were monitored until rejection occurred (blood glucose > 11 mMol/L) and kidney biopsies were taken every second day for immunohistological examination. In allotransplanted mice, rejection occurred after a mean of 15 +/- 4 days, in concordant xenotransplanted mice after a mean of 10 +/- 3 days and in the discordant xenotransplanted mice after a mean of 8 +/- 1 days. The immunohistological analysis showed in both xenotransplantation models a deposit of IgM and C3 surrounding the grafted cells, starting at day 1 and persisting until rejection, associated with the presence of Mac-1 positive cells. The intensity of the humoral response was moderate to important in the concordant group, but very strong and unchanged until rejection in the disconcordant group. An invasion with CD4+ and CD8+ cells started between day 4 and 6 in both groups, progressively increasing until rejection. In the allotransplantation model, no humoral response was detectable and the cellular response started between day 10 and 12 after transplantation. We conclude, that a cellular response is involved in the rejection process of both concordant and discordant xenotransplanted islets of Langerhans. Compared to an allotransplantation model, the humoral response does not destroy the function of transplanted islets, but could trigger or accelerate the cell-mediated response.

Mini-review: tumor necrosis factor (TNF) and TNF soluble receptors (TNF-sR) in liver disease and liver transplantation

Tumor necrosis factor (TNF) is a powerful cytokine with an important role in the inflammatory acute phase response and in the activation of the immune system. It exerts its action through the adherence to cellular receptors, known as the TNF-R55 und TNF-R75. High levels of these receptors are present in the blood in a soluble form and binding circulating TNF can neutralise its systemic effects. Although the knowledge on the biology of TNF and TNF-sR is progressing rapidly, little is known on the action of this cytokine and of its soluble receptors in liver disease and liver transplantation. The literature on the subject is reviewed, and trends for future research are discussed.

[Results of liver transplantations in Geneva or 32 consecutive transplantations without mortality in 2 years]

Between 1 january 1992 and 31 december 1993, 32 liver transplantations were performed in 29 patients (5 transplants in 3 children and 27 transplants in 26 adults) at Geneva University Hospital. Despite 5 super-urgent transplantations (3 fulminant hepatitis, 1 end-stage Wilson disease and 1 primary nonfunction), all patients are still alive and all have lived more than 10 months. On 1 october 1994, all patients were at home and 93% were in good general condition. No patient of this series had been transplanted for cancer and all patients positive for hepatitis B surface antigen receive long-term administration of anti-HBs immune globulin: in this respect, the long-term mortality risk of the present series of patients seems to be very low. Although these results highlight that liver transplantation can be performed safely by a competent medico-surgical team, two significant difficulties have to be outlined. First, patients are likely to die on the waiting list due to unavailable grafts, especially in emergency cases. Second, the postoperative period of patients with decompensated end-stage liver disease at the time of liver transplantation is still one of high morbidity. These facts underline that chronic liver disease patient should be evaluated for liver transplantation prior to the terminal decompensated stage of the disease, when the candidate's invariably poor general condition precludes successful liver transplantation.

Enhancement of liver hemangiomas on T1-weighted MR SE images by superparamagnetic iron oxide particles

OBJECTIVE

Superparamagnetic iron oxide (SPIO) particles are phagocytosed by cells of the macrophage-monocytic phagocytic system. They are usually used in MRI as a negative contrast agent, because of their strong T2* effect, to improve detection of tumors in the liver and spleen. However, they also have a potent T1 relaxivity. In the current study, we describe this T1 effect in liver hemangiomas.

MATERIALS AND METHODS

Twelve patients (nine women and three men, aged from 38 to 76 years) with liver hemangiomas were examined by means of MRI at 1.5 T before and after intravenous administration of SPIO particles at a dose of 15 mumol Fe/kg body wt. Signal intensity was measured from regions of interest.

RESULTS

Whereas on postcontrast T2-weighted SE images the hemangiomas showed on average a signal drop of 20% (p = 0.011) and 49% (p = 0.001) (first and second echo, respectively), their signal increased by 106% (p = 0.001) on postcontrast T1-weighted SE images.

CONCLUSION

The T1 effect (signal enhancement) we observed in liver hemangiomas after infusion of SPIO particles could prove to be a useful new diagnostic feature that would help characterize these common lesions and differentiate them from other liver tumors.

Vecuronium neuromuscular blockade reflects liver function during hepatic autotransplantation in pigs

BACKGROUND

Rapid assessment of hepatic function early after reperfusion of the liver graft is of great importance, because it may allow for prompt detection of incipient hepatic graft failure. The current study was undertaken to determine whether the continuous recording of neuromuscular transmission could be used as an on-line assessment of hepatic function during liver transplantation when a muscle relaxant with high hepatic uptake is used.

METHODS

We quantified and compared the effect of liver exclusion and graft reperfusion on the level of vecuronium-induced neuromuscular blockade in nine pigs studied twice within 3 days. During the 1st day (control session), an intravenous infusion of vecuronium was administered to maintain a constant 90-95% twitch depression during 180 min. The twitch response was then allowed to recover spontaneously to 75% of its prerelaxant value. Neuromuscular transmission was continuously measured on the right anterior leg using an acceleration transducer. During the same time period, the metabolic rate of 14C-labeled aminopyrine (a well-established quantitative test of the liver microsomal function) was determined by measuring the excretion of 14CO2 in expired air after administration of an intravenous bolus of 14C-labeled aminopyrine. Two days later, the pigs underwent a hepatic autotransplantation, during which vecuronium was administered to maintain a constant 90-95% twitch depression. After reperfusion of the liver graft, the vecuronium infusion rate was maintained at its anhepatic level, and the recovery index of the neuromuscular blockade (the time from 25% to 75% recovery of twitch height) was calculated. The aminopyrine breath test was performed during the last 30 min of the anhepatic phase, and during 3 h after reperfusion of the liver graft.

RESULTS

During control studies, the mean infusion rate of vecuronium was 1.30 +/- 0.33 mg.kg-1.h-1 and the recovery index was 3.4 +/- 0.5 min. During liver dissection, the infusion rate of vecuronium was similar to the control value (1.18 +/- 0.16 mg.kg-1.h-1), then considerably decreased to 0.05 +/- 0.03 mg.kg-1.h-1 during the anhepatic phase. After reperfusion of the liver graft, the recovery index was markedly prolonged to 35.5 +/- 15.8 min, indicating a prolongation of the recovery of neuromuscular blockade by a factor of 10.4. Excretion of 14CO2 was equal to zero during the anhepatic phase and then increased to 0.19 +/- 0.11% during the 1st h after reperfusion of the liver graft, an excretion rate corresponding to 11.2% of control conditions. The relationship between individual changes in the recovery index of the neuromuscular blockade and 14CO2 excretion in expired air after reperfusion of the liver graft showed a strong significant correlation (r2 = 0.71).

CONCLUSIONS

These results indicate that, compared with the control studies, there is a similar decrease in the recovery rate of vecuronium-induced neuromuscular blockade and in the metabolic rate of 14C-labeled aminopyrine during the progressive recovery of hepatic function immediately after unclamping of the liver vessels. Metabolism of 14C-labeled aminopyrine increased progressively during the reperfusion phase. Therefore, recording of neuromuscular transmission during liver transplantation could serve as a continuous and easy to perform assessment of liver graft function provided that a muscle relaxant with a high hepatic uptake is used for neuromuscular blockade.

[Prevention of viral recurrence following liver transplantation for post-hepatitis B and B-delta cirrhosis]

The incidence of recurrence of hepatitis B virus (HBV) following orthotopic liver transplantation (OLT) is as high as 80% when no attempt at prevention has been considered. HBV reinfection is associated with the reappearance of hepatitis B surface antigen (HBsAg) and HBV DNA in serum and, in most cases, with rapid severe graft damage. Immunoprophylaxis using polyclonal anti-HBs immunoglobulins reduces the risk of recurrence but this long-term therapy remains highly expensive. In this report, we use fresh frozen plasma (FFP) with high titers of anti-HBs immunoglobulins in an attempt to reduce HBV recurrence. From July 1987 to September 1993, 11 patients underwent OLT for HBV-related liver disease (18% of our OLT patients). FFP were administered to 6 patients continually for 7 to 46 months. Only one patient, under long-term immunosuppressive treatment before OLT, was reinfected 7 months after OLT. Rapid development of graft failure was observed with histologic manifestations of a fibrosing cholestatic hepatitis, leading to patient death after 12.5 months with concomitant bacterial infection. In this protocol, the rate of reappearance of HBsAg was 17%, a figure which can be favorably compared with other reports. All patients were subsequently tested for HCV and HIV and remained negative. In conclusion, FFP with high titers of anti-HBs immunoglobulins is at least as effective as polyclonal anti-HBs immunoglobulins in reducing the rate of HBV recurrence following OLT. The estimated cost of this new immunoprophylaxis method is less than 10% of the classical prophylaxis based on purified human polyclonal anti-HBs immunoglobulins.

[Cytomegalovirus in liver transplantation: incidence and groups at risk]

Cytomegalovirus (CMV) belongs to the family of Herpes viridae and has become the single most important viral pathogen in clinical transplantation. This is an endemic and ubiquitous virus. After transplantation it is necessary to distinguish CMV infection (positive seroconversion and/or isolation of the virus in the blood, urine, sputum or tissues in the absence of clinical symptoms) from CMV disease, which is a clinical expression of viremia in association with a documented CMV infection. The overall incidence of CMV infection in transplant recipients is about 50% and the incidence of CMV disease ranges from 15 to 25% whatever the transplanted organ. In this study (52 liver transplantations in 48 patients), 12 patients had CMV infection and 10 patients developed CMV disease (24%). The onset of CMV disease was 33 +/- 7 days after transplantation. Cytomegalovirus hepatitis was observed 7 times, CMV pneumonia once and 2 CMV infections characterized by oscillating fever in association with a hematological syndrome. 8 patients were treated with intravenous gancyclovir (DHPG, 9-[1,3-dihydroxy-2-propoxymethyl]-guanine) for 15 days and 2 patients by reduction of their immunosuppressive therapy only. There were significantly more (p < 0.05) opportunistic infections and/or bacteremia in patients with CMV disease. The association of CMV IgG negative recipients and CMV IgG positive donors appeared to be a significant factor (p < 0.05) for CMV disease. The number of transfusions, the level of immunosuppression and the absence of prophylaxis did not influence the incidence of CMV disease. Despite prolonged hospitalization and increased morbidity, there were no deaths in patients who developed CMV disease, which is good evidence of the efficacy of gancyclovir.(ABSTRACT TRUNCATED AT 250 WORDS)

[Pruritus associated with liver disease: propofol, a new therapeutic approach?]

Pruritus is a severe and troublesome symptom in patients with cholestasis and is often difficult to treat. Propofol was recently shown to be efficient in the treatment of pruritus secondary to spinal morphine administration. In a prospective, randomized, double-blind, cross-over and placebo controlled study, 20 patients received 1 dose of propofol (15 mg) and 1 dose of Intralipid (1.5 mg) during a 2-day study period. Pruritus was assessed by a visual analogue scale from 0 (no pruritus) to 10 (most severe pruritus imaginable). Treatment success was defined as a decrease in pruritus of at least 4 points on the scale in 80% of the patients receiving propofol and in 15% of those receiving intralipid (p < 0.05). Discomfort on injection was observed in 15% under propofol treatment. In conclusion this study shows that subhypnotic doses of propofol are effective for the short-term symptomatic relief of pruritus associated with liver disease. At the dose administered, side effects were rare and minor.

Intrahepatic biliary lesions following blunt liver trauma in children--is nonoperative management or conservative operative treatment always safe?

Nonoperative management of blunt liver injuries has become standard care for children, in the absence of hemodynamic instability. However, attention has to be drawn to biliary complications which can manifest themselves after a latent period, even in the presence of rupture of main biliary ducts. Peripheral bile duct lesions are easily treated by wide drainage. However, the extremely rare intrahepatic main bile duct lesions require other treatments. We report 2 cases of severe liver trauma associated with intrahepatic bile duct lesions: the first, managed nonoperatively, developed biliary peritonitis on day 21. Lesions of the main right biliary ducts were discovered. Because the right liver vascularization was not compromised, an intrahepatic biliary reconstruction was performed through a large hepatotomy according to the functional anatomy. The second child, who had an emergency laparotomy on admission, suffered nevertheless from a bilioma, drained on day 38. Because of increasing daily bile flow through the drain a second laparotomy was performed that demonstrated a biliary leak from a main segmental duct. Resection of the segment cured the patient. These two cases illustrate the occurrence of intrahepatic main bile duct lesions, clinically apparent after a latent period, following blunt trauma of the liver treated by nonsurgical or conservative surgical management. Intrahepatic biliary reconstruction is an alternative to liver resection when viable vascularization of the involved sector justifies its preservation.

[Transplantation of islets of Langerhans in man]

Islet of Langerhans transplantation is an alternative to whole pancreas transplantation for type I diabetic patients, in whom exogenous insulin therapy has not prevented the occurrence of systemic complications. Thanks to a new isolation technique of human islets, 45 patients have been transplanted worldwide since 1988, of whom only 7 have become totally insulin-independent. Rejection and quality of the islet preparations are problems which remain to be solved. Autotransplantation of islets has been proposed in patients undergoing a pancreatectomy for benign disease. The present report concerns two of our patients who had a pancreatectomy with islet autotransplantation. Both patients are insulin-independent 3 and 11 months postoperatively, with satisfactory metabolic tests. Islet autotransplantation can be proposed when pancreatectomy for non-malignant disease is performed. This method may prevent the development of insulin-dependent diabetes, known to be particularly labile. Because of the sophisticated technical procedures required, human islet isolation is at present only performed in a small number of medical centers and still is in the field of medical experimentation.

[Islet of Langerhans transplantation in humans]

Islet of Langerhans transplantation is an alternative to whole pancreas transplantation for type I diabetic patients, in whom exogenous insulin therapy has not prevented the occurrence of systemic complications. Thanks to a new isolation technique of human islets, 45 patients have been transplanted worldwide since 1988, of whom only 7 have become totally insulin-independent. Rejection and quality of the islet preparations are problems which remain to be solved. Autotransplantation of islets has been proposed in patients undergoing a pancreatectomy for benign disease. The present report concerns two of our patients who had a pancreatectomy with islet autotransplantation. Both patients are insulin-independent 3 and 11 months postoperatively, with satisfactory metabolic tests. Islet autotransplantation can be proposed when pancreatectomy for non-malignant disease is performed. This method may prevent the development of insulin-dependent diabetes, known to be particularly labile. Because of the sophisticated technical procedures required, human islet isolation is at present only performed in a small number of medical centers and still is in the field of medical experimentation.

Sequential changes in the splanchnic circulation during continuous endotoxin infusion in sedated sheep: evidence for a selective increase of hepatic artery blood flow and loss of the hepatic arterial buffer response

On-line recording of the sequential changes in systemic, pulmonary, mesenteric, hepatic and renal circulations during onset of endotoxaemia and at 24 h of established hyperdynamic sepsis were evaluated in seven chronically instrumented and sedated sheep receiving a continuous intravenous infusion of Escherichia coli endotoxin (20 ng min-1 kg-1). A transient and significant (P < 0.05) pulmonary arterial vaso-constriction was noted after 13 +/- 4 min, and was followed immediately by a simultaneous significant decrease of coeliac trunk, superior mesenteric artery, and portal vein blood flow to below 50% of baseline values. The superior mesenteric artery and portal vein blood flows partially recovered pre-endotoxin levels to 69 and 75% of baseline, respectively, after 70 min of endotoxin infusion. In contrast, the coeliac trunk blood flow remained reduced for a more prolonged period of time, but then completely recovered baseline values at 100 min. The response of the hepatic artery was biphasic, and consisted of a transient (5-10 min) vasoconstriction at 40 min followed by transitory increase of hepatic artery blood flow reaching a maximum of 921% of baseline values at 102 min. Contrasting with the early changes observed in mesenteric vascular resistances mostly unrelated to systemic haemodynamics, the response of the renal vasculature appeared to be more dependent on changes of renal perfusion pressure. A follow-up at 24 h revealed that the continuous intravenous infusion of endotoxin reproduced some of the most characteristic features of human sepsis with increased cardiac output and decreased vascular resistances of all vascular beds. We conclude that hepatic artery blood flow is selectively and considerably increased in early endotoxaemia in sheep independently of changes in portal vein blood flow, suggesting a disregulation of the physiologic hepatic arterial buffer response, most probably secondary to an increased liver oxygen demand required for phagocytosis, transport, and digestion of the the sudden overload of bacterial endotoxins.

Subhypnotic doses of propofol relieve pruritus associated with liver disease

BACKGROUND

Pruritus is a severe and troublesome symptom in patients with cholestasis and is often difficult to treat. Propofol was recently shown to be efficient in relieving pruritus secondary to spinal morphine administration. The efficacy of propofol was therefore investigated in patients with pruritus associated with liver disease.

METHODS

In a prospective, randomized, double-blind, crossover, placebo-controlled study, 10 patients received 2 doses of propofol (1.5 mL = 15 mg) and 2 doses of placebo (1.5 mL of Intralipid, Kabi-Pharm., Helsinki, Finland) during a 4-day study period. Pruritus was assessed by a verbal rating score from 0 (no pruritus) to 10 (most severe pruritus imaginable). Treatment success was defined as a decrease of pruritus of at least 4 points in the verbal rating score.

RESULTS

Treatment success was achieved in 85% of the patients receiving propofol and in 10% of those receiving Intralipid (P < 0.01). Discomfort on injection (15%) and slight dizziness (10%) were observed with propofol treatment.

CONCLUSIONS

This study shows that subhypnotic doses of propofol are effective for the short-term symptomatic relief of pruritus associated with liver disease. At the dose used, side effects were rare and minor.

Recent results of elective open cholecystectomy in a North American and a European center. Comparison of complications and risk factors

Results of elective open cholecystectomy in 1252 patients treated in a North American and a European center were examined using a recent standardized classification of complications. Although there were significant differences between centers in population age, rate of concomitant disorders, and numbers of operators, the frequency and severity of complications were comparable. There were no deaths, but 12% and 14% of the patients developed complications in the two centers. About 6% of the patients developed grade I complications. Grade II complications were noted in 6% and 8%, and grade III in 0% and 0.3%. Using univariate and multivariate analysis, individual risk factors for developing complications were found to be different in the two centers. Two preoperative scoring systems, ASA and a simplified APACHE II, were predictive for complications in both centers, but did not account for all risk in these patients. Data from the two centers could not be combined because of significant interaction between risk factors and center. Elective open cholecystectomy is a safe procedure, particularly in terms of highly morbid complications and death. Generalization of risk factors identified in a particular center may be misleading because local conditions may significantly affect risk factors for complications. The data also demonstrate the advantages of a uniform way of reporting surgical complications, which may permit meaningful comparisons among centers.

[Safety of cholecystectomy by laparotomy in elective situation and in emergency]

Cholecystectomy is the only effective treatment of gallbladder stones. A retrospective study was carried out on results of 658 cholecystectomies by laparotomy without choledochotomy performed between January 1987 and December 1989, to determine morbidity and mortality of elective and emergency surgery and by age. Operations for tumors of the gallbladder and choledolithiasis were not included in the analysis. During this period, cholecystectomy was performed electively in 387 cases and under emergency conditions in 261 patients. Mortality and post-operative morbidity were 0% and 14.7% respectively after elective surgery, increasing to 1.1% (Fisher = 0.0617) and 25.2 (p = 0.0004) respectively after emergency operations. This large increase in postoperative morbidity in urgent cases was due to an increase in systemic and not local complications, as a result of the higher proportion of emergency operations with advancing age. Since elective cholecystectomy is safe it can be proposed to patients with symptoms, including the elderly. It is difficult at present to compare results of cholecystectomy by laparotomy with those of laparoscopy since the average age of in the latter category is markedly lower and the number of acute cases still low. The principal advantage of celioscopy could be a long term reduction in systemic complications in emergency operations.

Gallstone ileus and bowel perforation after endoscopic sphincterotomy

Gallstone ileus as a complication of endoscopic sphincterotomy (ES) is exceptional, and this is only the second reported case. The present case is unique in that there was no previous instrumentation to the papilla, the bowel was obstructed and perforated, and the patient survived. This case again points out the danger of performing ES for large common bile duct stones. When a large stone is not extracted after ES, close monitoring is mandatory until unequivocal stone passage through the intestine is proven. In both cases reported so far, the lack of adequate monitoring after failure of stone extraction by ES was critical to the severity of gallstone ileus.

Elective hepatic resection in the elderly

This retrospective review assessed the safety and validity of elective liver resection in patients older than 64 years of age. In all, 293 patients underwent elective liver resection over a 23-year period (1967-1990). Fifty-two patients (18 per cent) were older than 64 (maximum 84, mean 70.4) years and all but four of these did not have cirrhosis. In this older subgroup, indications for resection were liver metastases in 30 patients, primary malignancy in 16, benign tumours in five and multiple abscesses in one. There were 21 major resections, with two deaths from hepatic failure, and 31 minor resections, with one death from cardiac failure (total mortality rate 6 per cent). During the same period, there were seven deaths after elective resections performed in 222 patients without cirrhosis who were younger than 64 years (P = 0.39). Mortality rate and duration of postoperative hospital stay were not related to the extent of liver resection nor to patients' grading according to the American Society of Anesthesiologists' criteria. Intraoperative blood loss was the only parameter found to influence mortality rate (P = 0.008) and duration of hospital stay (P = 0.04). Elective liver resection can be safely undertaken in elderly patients without cirrhosis, provided that intraoperative blood loss is minimized.

[Who are the candidates for liver transplantation?]

Over the past 12 years, new immunosuppressive agents, better knowledge of anesthesiology and postoperative reanimation as well as refinement in surgical technics modified the indications for and results of orthotopic liver transplantation (OLT). At the beginning of the OLT era, liver tumors that could only be removed by total hepatectomy were one of the most frequent indications. Nowadays, this indication is mostly abandoned in view of a high rate of recurrence and poor long-term results. In contrast, the prognosis of fulminant hepatic failure has been dramatically improved by OLT, once efficient organization systems allowed adequate organ supply and emergency transplantation within a few hours. Three main groups of diseases (cholestatic diseases, inborn errors of metabolism and parenchymal diseases) can be treated by OLT with excellent results (actuarial survivals of 80 to 90% have been reported at one and 2 years). Later graft dysfunction is rare except for virus B recurrence. Primary biliary cirrhosis and the group of inborn errors of metabolism are regarded as the optimal indications of OLT in adults and children respectively. Precocious evaluation of patients, before advanced stages of the disease associated with multiple complications, should prevent them from dying on a waiting list and decrease operative as well as early postoperative risks. Not only does OLT provide mere survival (among 5 patients with lethal hepatic disease, 4 are alive at 2 years from OLT), it also provides a regained quality of life with a virtually normal (for the price of a daily medication intake) family, professional and sportive life. Such achievements prompt us today to propose early transplantation to these patients.

[Impact of organ shortage on the transplantation program]

The purpose of the study was to evaluate the consequences of a recent progressive shortage of donor organs on our different transplant programs. Although the waiting time before transplantation remained in general relatively short (4.6 [mean], 0-3, 0-10 months for renal, liver and heart transplantation, respectively), patients started to accumulate on our waiting list during the last year (1990) of the study (kidney transplantation). Furthermore some patients clearly deteriorated, other died awaiting transplantation (18% and 15% of the patients listed for liver and heart transplantation, respectively). In emergency, organs were provided most often by neighbouring foreign centers. Given these facts adhesion to supranational donor networks should be considered.

Propofol and cholestatic pruritus

Hepatic cholestatis is frequently associated with pruritus. This pruritus is often intractable and resistant to conventional treatment. We treated three patients with intractable cholestatic pruritus with subhypnotic doses of propofol, a new intravenous anesthetic induction agent. All patients rapidly became itch- and scratch-free for a period of 60-90 min. No sedation occurred; no other side effects were observed.

[Aminopyrine breath test in hepatic auto-transplantation in pigs]

The aminopyrine breath test (ABT) was performed during hepatic autotransplantation in the pig. The test is reproducible in this animal and only hepatic cytochromes perform the demethylation of aminopyrine. Ischemia, varying from 90 to 200 minutes, generated a major decrease in the elimination of the 14CO2 and a marked change in the elimination curve. In this specific model it was not possible to assess survival of the animal by the ABT.

[Liver transplantation for primary biliary cirrhosis]

Primary biliary cirrhosis (PBC) is regarded as one of the optimal indications for orthotopic liver transplantation (OLT) in adults. Between July 1987 and August 1991, 7 patients had PBC as the indication for OLT. 6 were transplanted and one patient is still on the waiting list. The patients' mean age was 47 years (range: 39 to 59) and the time from diagnosis to indication for OLT was 4, 7, 8, 10, 12, 15 and 17 years. Variceal hemorrhage episodes treated by sclerotherapy (plus porta-caval shunt in one patient) occurred in 3 patients before OLT. All suffered from jaundice (mean bilirubin 232 mumol/l, range 116 to 536), weakness, anorexia and pruritus. There were no deaths in this series during a mean follow-up time of 26 months (range 6 to 43). With the exception of osteopenia, all complications of chronic liver disease were reversed by OLT. Despite numerous postoperative problems (e.g. reoperations, intense rejection episodes, cytomegalovirus infections and lumbar column fractures), the quality of life is excellent for these 6 patients. Mean bilirubin at time of last follow-up was 18 mumol/l (range 8 to 26). No evidence of PBC recurrence was found. Based on international experience confirmed by this series, we support the notion that no patient suffering from advanced PBC should be denied OLT whenever possible.

Flushing technique in the management of retained common bile duct stones with a T tube in situ

Over a 12-year-period, 6046 cholecystectomies and 918 common bile duct explorations were undertaken with 697 stone-positive choledochotomies (76 per cent). Forty patients (5.7 per cent) had retained common bile duct stones with a T tube in situ. Twenty-eight patients underwent flushing of the common bile duct with a continuous infusion of heparinized saline solution with parenteral aminophylline to induce relaxation of the sphincter of Oddi. Complete duct clearance was achieved in 17 patients; infusion was stopped in four patients and no deaths occurred. The use of percutaneous stone extraction (Burhenne's technique), gave an overall successful common bile duct clearance rate of 86 per cent. The flushing technique represents the first step in the non-operative management of retained common bile duct stones in patients with a T tube in place. It is a safe and effective method for use in the early postoperative period with a prolongation of hospital stay of not more than 1 week.

Influence of hepatic dysfunction on cyclosporine metabolism in the pig

Cyclosporine (CyA) is eliminated from the body via biliary excretion at a rate directly proportional to bile production and the functional status of the liver. Previous reports demonstrated that disturbances in the hepatic excretory function with a rise in the plasma bilirubin level are positively correlated with high blood concentrations of CyA and CyA plus metabolites (CyA + M). Less information is available about the blood concentrations of the CyA parental substance or CyA metabolites in the case of liver dysfunction when there was no elevation of serum bilirubin content. To answer this question, we compared the pharmacokinetic profile of CyA in a cholestatic and in a ischemic model in pigs. Our results show that in pigs receiving a single dose of CyA after liver ischemia, the blood concentrations of CyA and CyA + M are significantly increased independently of the serum bilirubin concentration, probably through a slow down of CyA metabolism by impairment of cytochrome P450 III A.