[Rehabilitation of patients with alcoholic liver cirrhosis after orthotopic liver transplantation: a 7-year follow-up]

Alcoholic liver cirrhosis is the main indication for orthotopic liver transplantation. Since 1988, 52 patients with alcoholic liver cirrhosis have been transplanted at the Department of Surgery of the University of Heidelberg. The survival rates are as follows: 73% of the patients survived for 1 year, 68% for 2 and 3 years, 64% for 4 years, and 57% survived for 5 years. After transplantation, recidivism occurred in 6 patients. Remarkable in this case was the fact that all 6 patients had a relatively short period of abstention prior to surgery (2 to 5 months). In 12 patients, a small carcinoma was found in the cirrhotic liver. This had neither been seen previously by ultrasound nor by computer tomography. In summary, orthotopic liver transplantation is an excellent mode of treatment in end-stage alcoholic liver cirrhosis. However, the patients have to be carefully selected in order to avoid recidivism following transplantation.

[Leiomyosarcoma of the inferior vena cava]

HISTORY AND CLINICAL FINDINGS

In a 34-year-old woman who underwent ultrasound investigation because of recurrent pyelonephritis a space-occupying lesion in the liver was an incidental finding. Computed tomography (CT) and magnetic resonance imaging (MRI) confirmed a tumour in segment I of the liver. The patient had been on contraceptives for 12 years. She had no symptoms.

INVESTIGATIONS

Laboratory tests, including tumour markers, were unremarkable. Diagnostic tests to exclude malignant tumour with metastases were negative (thyroid scintigraphy, mammography, coloscopy and gastroscopy). Further tests (ultrasound, coeliaco-mesentericography, hydro-CT and spiral CT, MRI) revealed a tumour, 5 x 4 x 4 cm, in segment I of the liver, most likely an adenoma. Surgical intervention was indicated by the size and questionable malignancy of the tumor.

TREATMENT AND COURSE

At operation a tumour was found which originated from the inferior vena cava (IVC) and displaced segment I of the liver. The tumour was resected and the venous wall reconstructed with a Goretex patch. Histological examination indicated a poorly differentiated leiomyosarcoma of the IVC. Adjuvant radiotherapy was undertaken postoperatively. There has been no evidence of recurrence after 10 months.

CONCLUSIONS

Leiomyosarcoma of the IVC can be mistaken, both by ultrasound and tomographic diagnostic procedures, for a tumour in segment I of the liver, especially an adenoma. A leiomyosarcoma of the IVC should be included in the differential diagnosis of an hepatic tumour that lies close to segment I of the liver.

[Significance of diagnostic imaging for determining surgical indications in solid liver tumors]

Radiological imaging is essential for the differential-diagnostic appraisal and the assessment of size, number, and localization of neoplastic liver lesions. The results determine the decision for or against operation and the surgical strategy. Moreover, oncological contraindications against surgery are recognized by imaging procedures. Technical refinements of imaging comprise improved quality of ultrasound and of computed tomography and fast sequences in magnetic resonance imaging. Special investigational protocols and specific contrast agents for ultrasonography and magnetic resonance technique are highly relevant for clinical practice. The value of diagnostic procedures is demonstrated by our own experience. The differential use of imaging procedures, technical and methodological performance and the final diagnostic interpretation require a high standard of expertise. Diagnostic accuracy is limited by technical and biological factors.

Recurrent hepatitis C virus infection after liver transplantation--long-term follow-up with respect to the HCV genotypes/subtypes

BACKGROUND/AIMS

Various factors may affect the postoperative course in recurrent hepatitis C virus (HCV) infection after liver transplantation (OLT). The aim of our study was to evaluate the potential role of HCV genotypes and immunosuppressive treatment.

METHODS

17 liver allograft recipients, HCV-RNA positive prior to OLT, were followed 26-102 months postoperatively. The diagnosis of HCV infection was based on clinical, serological and histological findings and detectable HCV-RNA in serum. The genotypes/subtypes were evaluated by a "reverse line probe" assay.

RESULTS

After OLT hepatitis C viremia was evident in 16 of 17 allograft recipients (94%). Two patients acquired HCV infection after transplantation (incidence 0.84%). Clinically eight of 18 viremic patients remained asymptomatic. Ten of 18 had an acute hepatitis (eleven to 27 weeks after OLT), of those nine patients developed chronic hepatitis (hepatic activity indices: grade 1-3) with progression to fibrosis in two patients. One patient subsequently developed cirrhosis. Subtype 1 b was predominant (eleven of 18 patients). After transplantation subtype 1 b was not associated with a higher rate of recurrent hepatitis compared to other genotypes/subtypes (45% in type 1 b vs. 71% in type "non-1 b"; n.s.).

CONCLUSION

Identical HCV genotypes/subtypes before and after OLT indicate a recurrent rather than a postoperatively acquired HCV infection of the allograft. Despite viremia most patients had no or mild to moderate hepatitis in the long-term follow-up. Different HCV genotypes were not associated with specific clinical courses of recurrent HCV infection after OLT.

Two-year data from the European multicentre tacrolimus (FK506) liver study

To provide a more definitive assessment of the efficacy and safety of tacrolimus therapy in comparison with cyclosporin, the extended follow-up of the European multicentre study is reported. Two-year Kaplan-Meier estimates indicated significant reductions in acute (tacrolimus 45.4%, cyclosporin 55.8%; P = 0.006), refractory (1.2% versus 6.4%; P = 0.003) and chronic rejection (2.0% versus 6.9%; P = 0.015) despite significantly lower steroid usage in patients receiving tacrolimus therapy. Patient and graft survival rates (80.6% versus 74.8% and 74.5% versus 70.0%, respectively) were also superior, although these failed to reach statistical significance. Safety profiles were comparable for most major categories (including renal, neurological and glucose metabolic disorders) and in certain aspects were more favourable for tacrolimus. Hypertension (28.0% versus 39.6%, P < 0.01) and cytomegalovirus infection (14.8% versus 22.3%, P < 0.01), two events with important long-term clinical consequences, were reported significantly less frequently. Hirsutism (0.0% versus 8.7%, P < 0.01) and gum hyperplasia (0.0% versus 2.3%, P < 0.05) were absent in patients receiving tacrolimus. Tacrolimus appears to provide effective and safe long-term immunosuppression.

Lymphocyte apoptosis induced by CD95 (APO-1/Fas) ligand-expressing tumor cells--a mechanism of immune evasion?

The CD95 (APO-1/Fas) system is an important mediator of T-cell cytotoxicity. We investigated this system in 22 hepatocellular carcinomas (HCCs) from patients. All HCCs had partially or completely lost the expression of the CD95 receptor constitutively expressed by normal liver cells and might thus evade CD95-mediated killing. We also considered a new mechanism of immune evasion, namely, the active destruction of T-lymphocytes by tumor cells expressing CD95 ligand (CD95L). CD95L messenger RNA and protein could be detected in the HCCs. In coculture experiments, HepG2 hepatoblastoma cells, expressing CD95L mRNA after treatment with cytostatic drugs, killed CD95+ Jurkat lymphocytes. Our data suggest that tumor cells can evade immune attack by down-regulation of the CD95 receptor and killing of lymphocytes through expression of CD95L.

Dopamine D2 receptor gene (DRD2) haplotypes in Caucasians

The human dopamine D2 receptor gene (DRD2) is considered a candidate gene for neuro-psychiatric diseases. We typed three new DNA sequence variants in DRD2 intron 4, intron 6 and exon 8, in combination with the known TaqI A restriction fragment length polymorphism (RFLP) and exon 7 311Ser/Cys in 106 unrelated psychiatrically healthy Caucasians. Based on the genotypic data we delineated 10 distinct DRD2 haplotypes and their genetic relationship. Our data provide evidence that the Taq A1 allele and the 311Cys variant are components of different groups of haplotypes though both variants have been speculated to be associated with alcoholism or schizophrenia in recent studies. Therefore we conclude that the prior knowledge of the frequencies and genetic relationships of DRD2 haplotypes will lead to the selection of more suitable intragenic markers for future association studies.

Recovery time and safe discharge of endoscopy patients after conscious sedation

The aim of this study was to identify the best method for determining when to safely discharge the endoscopy patient; specifically, it was designed to determine whether the patient's risk factors, intraoperative occurrences, and/or medications used during endoscopy should be used to determine the minimum length of stay postconscious sedation or whether a general policy can be used, as is currently practiced at many institutions. Preoperative, intraoperative, and postoperative data were collected on a convenience sample of 405 adult ambulatory outpatients undergoing upper endoscopy and/or colonoscopy. Subjects were also interviewed by phone within 48 hours of discharge to assess postdischarge complications and their duration. Age predicted length of time in recovery, but only 2% of the variation in recovery time was predicted by the study variables. Intraprocedure occurrences predicted postprocedure occurrence. The implications of these and other findings are discussed in relation to nursing practice and future research.

Kinetics of primary bile acids in patients after orthotopic liver transplantation

Administration of cyclosporin A (CsA) may induce cholestasis, and this effect has been attributed to impaired hepatocellular uptake, transport, secretion and intestinal absorption of bile acids. Disturbances of the enterohepatic circulation may affect metabolism of bile acids. To test whether liver transplantation and treatment with CsA alters pool sizes or synthesis and turnover rates, we determined kinetics of primary bile acids in patients after orthotopic liver transplantation on CsA. Two male and four female patients were studied 6-20 months after transplantation. They had no overt signs of cholestasis, graft dysfunction or rejection. Kinetics of cholic acid (CA) and chenodeoxycholic acid (CDCA) were simultaneously determined after oral administration of [24-13C]-CA and [24-13C]-CDCA on the basis of isotope dilution in a single pool of bile acids. Ten healthy volunteers served as controls. After orthotopic liver transplantation, pool sizes, fractional turnover rates and synthesis rates of both primary bile acids, CA and CDCA were not significantly different from control subjects. In spite of the known interference of CsA with the enterohepatic circulation of bile acids, in the majority of patients after orthotopic liver transplantation without cholestasis, graft dysfunction of rejection, treatment with CsA does not disturb kinetics of primary bile acids.

Aspergillus endocarditis, myocarditis and pericarditis complicating necrotizing fasciitis. Case report and subject review

A patient with Aspergillus endocarditis, myocarditis and pericarditis is described. A 55-year-old man developed necrotizing fasciitis of the lower abdominal wall, pelvis and right thigh. Despite aggressive surgical débridement and antibiotic coverage, the patient died of multisystem organ failure. Autopsy revealed Aspergillus thromboulcerative endocarditis, myocarditis and pericarditis, acute necrotizing fungal bronchopneumonia and mycotic dissemination to brain, kidney and thyroid gland. A review of the literature showed that in the absence of open-heart surgery Aspergillus endocarditis and myocarditis are very uncommon.

[Liver transplantation and diagnostic radiology: socioeconomic aspects]

PURPOSE

For calculating cost-effectiveness in the context of diagnosis related groups (DRG) we analysed all radiological examinations for 56 consecutive liver transplantations during the primary stay in the surgical department (1052 chest x-rays, 296 ultrasonographies, 216 colour coded duplex sonographies, 72 cholangiographies, 35 CT, 23 angiographies, one MRI and one embolisation).

METHODS

For calculation we used the reimbursement that the surgical wards received per patient day and the special fee for liver transplantation. We compared this with the refunds received by the department of radiology.

RESULTS

The hospital was reimbursed a total of 143785.80 DM per patient. The diagnostic and interventional procedures that were requested for the 56 patients amounted to a total of 225118.63 DM and 4019.96 DM per patient, respectively.

CONCLUSIONS

This means that only 2.8% of all the costs during and after liver transplantation were caused by the radiological examinations. This represents only a small portion of the expenses during the time in hospital, taking into account especially that patients after liver transplantation are at high risk for developing complications.

Improvement of hepatic microhemodynamics by N-acetylcysteine after warm ischemia

In this study we investigated the influence of N-acetylcysteine (NAC) on the hepatic microcirculation after warm ischemia by intravital fluorescence microscopy. Clamping of the left liver lobe was performed in 20 male Wistar rats for 70 min. The treatment group (n = 10) received 400 mg NAC/kg body weight 20 min prior to clamping. After reperfusion, acinar and sinusoidal perfusions were observed as well as the leukocyte-endothelium interaction. Phagocytic activity was assessed after application of latex beads. NAC reduced the number of nonperfused sinusoids in all acinar zones. A reduction in zone 1 (portal) was achieved from 15.5 to 7.1% (p < 0.0001), in zone 2 (midzonal) from 14.6 to 6.1% (p < 0.0001) and in zone 3 (central) from 11.9 to 2.9% (p < 0.0001). There were no significant differences in leukocyte adherence as well as in phagocytic activity detectable. We conclude that NAC improves hepatic microcirculation after warm ischemia by increasing sinusoidal blood flow.