[Orthotopic liver transplantation--indications and results]

Indications for and results of orthotopic liver transplantation (OLT) were modified over the past ten years by new immunosuppressive agents, earlier timing of transplantation and better knowledge of potential complications. In 1990, OLT appears justified in the treatment of all liver disease threatening life, in the absence of contraindications and other possible treatments. Between July 1987 and December 1990, 21 patients were transplanted at the Geneva University Hospital. Three children received part of an adult liver (two or three segments), using the reduced-size liver transplantation technique. Four OLTs had to be performed in an emergency situation. Two patients died within six months of transplantation, one after 7.5 months, and the last patient died after one year from cancer recurrence. 17 patients are presently alive (81%) at 4 to 39 months (median 14 months) following OLT. More than the mere survival, however, the quality of life regained after transplantation prompts us to consider transplantation early in the progress of the disease.

[Experience with a surgical mesh covering a hepatectomy incision]

A polyglycolic acid net (Vicryl) has been applied against the hepatectomy section of 27 patients (14% of all our liver resections) to complete its hemostasis. The indications for the use of this net were: the persistence of blood oozing and/or the necessity to shorten the operation. In one patient suffering from severe coagulopathy, active bleeding continued until the patient died; another patient bled until his blood dyscrasia was corrected. One case of abscess was encountered, and treated through a percutaneous approach. Although the achievement of perfect hemostasis is usual in surgical exeresis of the liver, a minority of patients can present with resistant bleeding of the resection slice, for which packing with a net may prove to be useful.

[Surgical treatment of hepatic hydatidosis]

Between January 1981 and December 1990, 41 patients were operated on for hepatic hydatid disease, representing 18% of the overall surgery for liver disease performed in our institution during the same period of time. The mean age of the patients was 39.5 years (range 17-71 years), 24 were females and 17 males. The most common clinical sign was abdominal pain (59%) with 3 patients jaundiced at the time of admission. 2 patients suffered from acute rightsided pneumonia, one of them with a very important productive cough due to bronchial perforation of the hydatid cyst of the liver. One patient was admitted due to anaphylactic shock with collapse. For 14 patients (34%) the discovery of the disease was casual, either by clinical hepatomegaly or by X-ray investigations performed for other reasons. We performed 18 pericystectomies, 4 subtotal pericystectomies and 16 liver resections. Only 3 patients were treated by partial cystectomy with removal of the prominent part of the cyst. Several other surgical procedures were performed concomitantly, including 2 pulmonary lobectomies, 1 cystojejunostomy, and pericystectomies for other hepatic or extrahepatic localizations of hydatid cysts. Rupture of the cyst into the bile duct was diagnosed in 13 patients. One patient presented with a peritoneal rupture of the cyst and 2 patients had a fistula through the diaphragm into the pleural cavity. Our postoperative morbidity is acceptable (10 patients, 25%). A bilioma and a biliary leak were successfully treated by percutaneous drainage, a postoperative hemorrhage required surgical treatment, four patients experienced pulmonary complications and the three others minor wound abscesses.(ABSTRACT TRUNCATED AT 250 WORDS)

[Ischemic colitis. Results of conservative treatment]

34 consecutive patients were admitted for ischemic colitis confirmed by colonoscopy, contrast enema, laparotomy, and/or post-mortem between 1984 and 1988. 13 underwent excisional surgery, usually at an early stage, because of acute abdomen. This study is devoted to the remaining 21 patients (62%), i.e. nearly two thirds of the whole series, who were treated conservatively (intravenous hydration and antibiotics). Our results suggest that (1) ischemic colitis usually affects elderly patients in whom an underlying cardiovascular disease is seldom found; (2) the right colon is infrequently involved, and (3) outcome is generally favorable in the absence of superimposed major pathology or of peritoneal signs which would require surgical exploration.

[Results of surgical treatment of ischemic colitis]

Between January 1984 and December 1989, 13 patients, aged 39 to 89 (median 63), underwent surgery for histologically proven ischemic colitis. Most suffered from pre-existing cardiovascular conditions (2 shortly after surgery for aortic aneurysm). One patient developed ischemia after the traumatic avulsion of the ileocolic artery and another after the spontaneous reduction of a strangled inguinal hernia. Diagnosis of ischemic colitis was made prior to operation in 4 instances only. The left colon was affected 5 times and the right colon 8 times (with the terminal coil of ileum 3 times). Treatment always consisted in segmental colectomy; laparotomy was used in 3 patients (2 to 7 reoperations). Colon anastomosis was performed directly 5 times, while 4 patients had secondary stomy closures; 2 patients still have their original stomy. Two patients died (15%), one of sepsis and the other following broncho-aspiration. The prognosis of ischemic colitis is rather favorable, even at the stage of transmural necrosis, provided all ischemic zones are resected. This is in contrast with the severe mortality of mesenteric infarcts, when extensive small bowel necrosis is found in association with colonic ischemia.

Dose requirements and plasma concentrations of pipecuronium during bilateral renal exclusion and orthotopic liver transplantation in pigs

We have studied five pigs undergoing bilateral clamping of the renal pedicles, seven pigs undergoing orthotopic liver transplantation and three control animals without surgery in order to examine the roles of the kidney and liver in the plasma clearance of pipecuronium. An i.v. infusion of pipecuronium was controlled to maintain a constant 90-95% twitch depression throughout the investigation. The right sciatic nerve was stimulated continuously with supramaximal stimuli at 0.1 Hz and the force of the corresponding evoked isometric muscle contraction was recorded continuously. Control pigs needed an infusion rate of pipecuronium 8-10.7 micrograms kg-1 min-1. In the renal group, it was necessary to reduce the infusion rate of pipe-curonium by about 25% after clamping both renal vascular pedicles (P less than 0.05 compared with controls); in pigs undergoing liver transplantation, it was necessary to reduce the rate by approximately 80% after clamping hepatic vessels (P less than 0.05 compared with controls and from the period after clamping of renal vessels). After hepatic recirculation, the infusion rate of pipecuronium was increased progressively to a rate which corresponded to 50% of baseline values (P less than 0.05 compared with the anhepatic phase and from controls). Plasma concentrations of pipecuronium were comparable in the three animal groups and did not change significantly during the study. These data suggest that the liver plays a more important role than the kidney in the plasma clearance of pipecuronium in pigs.

[Liver transplantation. Preliminary results in the district University Hospital of Geneva]

Between July 1987 and May 1989, 11 liver transplants were performed on 10 patients at the University Hospital of Geneva. Of 15 patients evaluated for elective transplantation, 10 were accepted and put on the waiting list. 5 patients were rejected because of a contraindication or because another treatment seemed preferable. 8 transplantations were eventually performed. Emergency transplantation was considered for 6 patients, but could be performed in only 3. Indications for transplantation were as follows: one hepatocellular carcinoma in a non-cirrhotic patient, 2 post-hepatitis cirrhoses (one B and one non-A-, non-B), 3 primary biliary cirrhoses, one autoimmune cirrhosis, one primary sclerosing cholangitis, one cirrhosis on alpha-1-antitrypsin deficiency, and one fulminant B-Delta hepatitis. Most of these patients had advanced liver disease and a limited life expectancy. 8 of the 10 patients transplanted are nevertheless alive and none is hospitalized at the present time. More than mere survival, however, quality of life regained after transplantation prompts us to consider transplantation early in the progress of the disease. Earlier evaluation of patients would make transplantation feasible soon after the first complication of the disease. This attitude would probably prevent patients from dying while on a waiting list and decrease operative as well as early postoperative risks. Better information and coordination regarding potential donors is necessary in Switzerland to obtain better results in organ transplantation.

Experimental porcine orthotopic liver transplantation: a training protocol for transplantation in humans

The authors suggest that, prior to human liver transplantations, exhaustive training be undertaken on an animal model in order to acquire the expertise required for this delicate procedure. The pig has considerable anatomic similarities to man, as well as a comparable physiological and hemodynamic sensitivity, and has been used as a model by our experimental team to perfect our clinical liver transplantation technique. In particular, a surgical model representing the adult donor/child recipient situation has been developed. Anesthesia, extracorporeal bypass procedure and the full surgical protocol are described. This operative protocol was elaborated to mimic as closely as possible the clinical situation. Our model also allowed us to undertake several relevant physiological and pharmacological studies during the transplantation procedure.

[Results of biliary surgery in a teaching center]

The last few years have seen the introduction of new medical approaches to treatment of gallstone disease. To investigate whether this was the consequence of disappointing results following surgical treatment, we undertook a one-year prospective study at the Clinic of Digestive Surgery in Geneva, a training center with an unselected patient population. From October 1986 to September 1987, 306 biliary operations were performed for calculous disease by 20 surgeons, most of whom were under training. Juniors were supervised by senior surgeons. Operative indications and management were based on the strict criteria established at our center. Over half the patients had suffered one or more complications of gallstone disease. Overall mortality and morbidity were 0.3% and 11.7% respectively. In conclusion, gallstone surgery, which is a definitive treatment, has provided us with very acceptable results and therefore should not be a reason for encouraging other conservative approaches in the treatment of gallstone disease.

Plasma concentrations of laudanosine, but not of atracurium, are increased during the anhepatic phase of orthotopic liver transplantation in pigs

To quantify the changes in plasma concentrations of atracurium and laudanosine induced by the lack of hepatic function and circulation, the authors studied nine domestic pigs (22-25 kg) undergoing an orthotopic liver transplantation, and three control animals without surgery, using atracurium as the muscle relaxant. After intubation facilitated by isoflurane 2-3%, anesthesia was maintained with isoflurane (0.5% in oxygen) and fentanyl (4 micrograms.kg-1.hr-1). Ventilation was controlled to keep end-tidal CO2 at 35-40 mmHg, body temperature maintained at 35.5-37.5 degrees C, and arterial pH at 7.35-7.50. The right sciatic nerve was stimulated with a nerve stimulator delivering a single twitch at 0.1 Hz with 0.2-ms duration, at supramaximal stimulation. The force of the corresponding evoked isometric muscle contraction was continuously measured by a force-displacement transducer. A single iv bolus of atracurium (2 mg/kg) was given to obtain a 90-95% twitch depression, followed 5 min later by a constant-rate iv infusion of atracurium at 120 micrograms.kg-1.min-1 maintained during the entire investigation. Blood samples for plasma atracurium and laudanosine concentrations were drawn every 15 min. In the control group, plasma concentrations of atracurium remained stable between 6.5-8.0 micrograms/ml following initial bolus injection; plasma concentrations of laudanosine increased during the first 60 min, then remained stable between 0.69-0.74 micrograms/ml up to the end of the study. In animals undergoing transplantation, plasma concentrations of atracurium remained stable between 10-12 micrograms/ml, despite a 90-min duration of liver exclusion.(ABSTRACT TRUNCATED AT 250 WORDS)

[1 year of multiple organ procurement using the Starzl technic of rapid cooling: personal results]

We did perform 20 multiorgan procurements in 1987, using the last technique described by STARZL. We were very favorably impressed by the security (all organs harvested achieved good long-term function), the rapidity (mean operative time 125 min) and the flexibility of the technique. Waiting lists for hearts and livers in Switzerland are now becoming long, and it seems thus essential that all usable organs can be retrieved for transplantation.

Hepatic trauma: risk factors influencing outcome

This retrospective study analyses the fate and associated risk factors of 99 patients who underwent laparotomy for hepatic trauma from 1977 to 1986. Blunt trauma (88 patients) and stab wounds (7 patients) had mortality rates of 36 and 14 per cent respectively. The overall death rate was 35 per cent. Multiple trauma patients had a significantly higher mortality for each additional system that was seriously injured. Pre-operative shock raised the mortality from 20 to 58 per cent (P less than 0.001). For patients over 50 years of age, the mortality rate increased from 30 (younger patients) to 63 per cent (P = 0.028). Minor hepatic wounds required relatively simple surgical measures in 60 patients, yet 13 died (22 per cent) of other causes. More sophisticated surgical management was applied to 27 major hepatic lesions, with 10 deaths (37 per cent). Twelve patients (seven with minor and five with major hepatic wounds) died before surgical treatment of the liver injury could be undertaken. The overall mortality rate of major hepatic wounds was 47 per cent and for minor wounds 30 per cent. However, the difference was not significant (P = 0.152). Resection was resorted to in 15 patients, 5 of whom subsequently died (33 per cent). Classical hepatic lobectomy led to 4 deaths (50 per cent). Among the 35 deaths, 6 were due to the hepatic trauma itself (5 exsanguinations and 1 intra-abdominal sepsis). Isolated hepatic injury was fatal in three patients. We believe that conservative surgical measures should be used whenever possible in patients with hepatic trauma, especially when risk factors are encountered.

[Application of computerized tomoscintigraphy in the detection of tumors using cobalt-57-marked bleomycin]

57Co-bleomycin scanning dates from the early 1970s, when the first results were presented by Renault et al. Since then there have been numerous publications concerning the high sensitivity of this type of study in the detection of pulmonary or cerebral neoplasms. In the region below the diaphragm, however, sensitivity was poor due to hyperactivity of the kidney, liver and bladder. To eliminate this problem the authors have used single photon emission computerized tomography (SPECT), and their department is currently investigating the sensitivity of this technique for the detection of neoplasms. Two typical cases are described which illustrate the value of this method in the detection of cancer.