How Do Hepatologists Gain Access to Liver Transplant Units?

Liver transplantation has evolved from an experimental treatment to be considered as the most effective therapy for end-stage liver disease and selected cases of hepatocellular carcinoma. Transplant hepatologists must have specific knowledge and abilities to treat those patients who receive a liver transplant. In Spain, approximately 1100 liver transplants are performed each year, and most centers assume both postoperative care and long-term follow-up, which has led to a significant work load in liver transplant units. Despite previous attempts to establish an official training program in hepatology, the Spanish health system does not presently have a specific liver transplant training program to guarantee that future needs of physicians are covered. Collaboration between health authorities and scientific societies is required to guarantee adequate assistance to liver transplant recipients in the future.

Prosthetic Abutment Height is a Key Factor in Peri-implant Marginal Bone Loss

In this study, we analyzed the influence of prosthetic abutment height on marginal bone loss (MBL) around implants in the posterior maxilla. In this retrospective cohort study, the radiographically determined MBL was related to the height of the abutments of internal conical connection implants at 6 and 18 months post-loading. Data were gathered on age, sex, bone substratum, smoking habit, history of periodontitis, and prosthetic features, among other variables. A linear mixed model was used for statistical analysis. The study included 131 patients receiving 315 implants. MBL rates at 6 and 18 months were mainly affected by the abutment height but were also significantly influenced by the bone substratum, periodontitis, and smoking habit. MBL rates were higher for prosthetic abutment < 2 mm vs. ≥ 2 mm, for periodontal vs. non-periodontal patients, for grafted vs. pristine bone, and for a heavier smoking habit. The abutment height is a key factor in MBL. MBL rates followed a non-linear trend, with a greater MBL rate during the first 6 months post-loading than during the next 12 months.

Liver transplantation as treatment in a massive metastasis from Gruber-Frantz pancreatic tumor: a case report

The Gruber-Frantz tumor or solid pseudopapillary tumor of the pancreas accounts for 1% to 2% of pancreatic tumors. It occurs more frequently among women between 20 and 40 years of age and in the Asian population. These tumors are of low malignant potential and show slow growth. The symptoms are subtle, the most striking being pain and an abdominal mass. The most common site is the pancreatic tail. The location and local invasion determine the surgical technique. With R0 resection, survival is 95% at 5 years. In 15% of cases metastatic disease appears, mostly in the liver. The treatment of liver metastases is surgical resection. In the case of multiple liver metastases, the treatment is controversial. QT has been used, as well as radiofrequency ablation, arterial embolization, and intraarterial chemotherapy. Herein we have described the case of a 44-year-old woman with massive liver metastases who did not respond to QT lines and underwent successful liver transplantation with survival free of recurrence at 1 year later. This is the first liver transplantation for a metastatic pancreatic pseudopapillary tumor in Spain and the second described in the literature.

Prognostic and developmental factors in patients receiving liver transplant due to hepatocellular carcinoma: one center's experience in the north of Spain

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the most frequent types of tumor. The aim of this study was to determine the survival of patients who had received liver transplants as a result of the disease.

METHODS

This observational follow-up study included 150 patients who received liver transplantations from June 1994 to December 2007. The study considered epidemiological and staging variables, tumor descriptions, and follow-up variables. We employed Kaplan-Meier methodology together with a Cox multivariate regression analysis.

RESULTS

The incidence of tumor relapse was 13.3%, with survival rates at 1, 3, and 5 years of 89.3%, 73.1%, and 61.4%, respectively. Variables that showed an independent effect to predict mortality were the degree of histological differentiation and of macrovascular invasion. Patients with poorly differentiated HCC had a 4.03 fold (95% confidence interval [CI]: 1.61-10.06) greater possibility of dying. Macrovascular involvement increased the risk of death (relative risk = 2.23), an effect that was at the limit of significance (95% CI 0.99-5.04).

CONCLUSIONS

The survival rate was consistent with the literature. Poor tumor differentiation and macrovascular involvement were independent predictors of mortality.

Functional heterogeneity of NMDA receptors in rat substantia nigra pars compacta and reticulata neurones

The nigra substantia nigra pars compacta (SNc) and substantia pars reticulata (SNr) form two major basal ganglia components with different functional roles. SNc dopaminergic (DA) neurones are vulnerable to cell death in Parkinson's disease, and NMDA receptor activation is a potential contributing mechanism. We have investigated the sensitivity of whole-cell and synaptic NMDA responses to intracellular ATP and GTP application in the SNc and SNr from rats on postnatal day (P) 7 and P28. Both NMDA current density (pA/pF) and desensitization to prolonged or repeated NMDA application were greater in the SNr than in the SNc. When ATP levels were not supplemented, responses to prolonged NMDA administration desensitized in P7 SNc DA neurones but not at P28. At P28, SNr neurones desensitized more than SNc neurones, with or without added ATP. Responses to brief NMDA applications and synaptic NMDA currents were not sensitive to inclusion of ATP in the pipette solution. To investigate these differences between the SNc and SNr, NR2 subunit-selective antagonists were tested. NMDA currents were inhibited by ifenprodil (10 microM) and UBP141 (4 microM), but not by Zn(2+) (100 nm), in both the SNr and SNc, suggesting that SNc and SNr neurones express similar receptor subunits; NR2B and NR2D, but not NR2A. The different NMDA response properties in the SNc and SNr may be caused by differences in receptor modulation and/or trafficking. The vulnerability of SNc DA neurones to cell death is not correlated with NMDA current density or receptor subtypes, but could in part be related to inadequate NMDA receptor desensitization.

Are motorway wildlife passages worth building? Vertebrate use of road-crossing structures on a Spanish motorway

Numerous road and railway construction projects include costly mitigation measures to offset the barrier effect produced on local fauna, despite the scarcity of data on the effectiveness of such mitigation measures. In this study, we evaluate the utility of different types of crossing structures. Vertebrate use of 43 transverse crossing structures along the A-52 motorway (north-western Spain) was studied during spring 2001. Research centered on wildlife passages (9), wildlife-adapted box culverts (7), functional passages (6 overpasses, 7 underpasses) and culverts (14), with marble dust being used to record animal tracks. A total of 424 track-days were recorded, with most of the larger vertebrate groups present in the area being detected. All crossing structure types were used by animals, although the intensity of use varied significantly among them (Kruskal-Wallis test, p<0.05); culverts were used less frequently than other structures. Crossing structure type and width were identified as the most important factors in their selection for use. Wildlife passages and adapted culverts allowed crossing by certain species (wild boar, roe deer, Eurasian badger), which do not tend to cross elsewhere. These results highlight the importance of using both mixed-type structures and wildlife passages in reducing the barrier effect of roads.

Reversal of cardiac cirrhosis following orthotopic heart transplantation

Irreversible hepatic cirrhosis greatly increases the risks attending heart transplantation (HT), and is accordingly considered to be an absolute contraindication for HT unless combined heart and liver transplantation can be performed. It is now recognized that hepatic cirrhosis can undergo regression if the source of insult is removed, but no cases of post-HT regression of cirrhosis of cardiac origin have hitherto been reported. Here we report a case of cardiac cirrhosis that underwent complete regression following orthotopic HT, and we discuss the implications of this case.

[Enucleation and evisceration: 370 cases review. Results and complications]

PURPOSE

To analyze the surgical results in 370 patients who underwent enucleation or evisceration at our center, during a period of 11 years (1990-2000), determining the kind of correction used and the complications associated with the procedure.

METHODS

This was a retrospective study of medical records from all patients who underwent surgery by the same surgeon (FS) in the Oculoplastic Department. Demographic data, diagnosis, previous and associated ophthalmic surgeries, implant or graft characteristics, follow up period and postoperative complications were determined in all patients.

RESULTS

One hundred sixty-one enucleations and 209 eviscerations were performed. Some kind of implant or graft was associated with 98.4% of these procedures. During the first 6 years of the study, lipodermal grafts were performed in 58.8% of the total, while in the last 5 years hydroxyapatite implants were performed in 90.9% of the cases. In 39 (10.6%) of 369 patients with registered follow up data, 58 complications requiring surgical correction were observed.

CONCLUSIONS

Hydroxyapatite implants gave an excellent anophthalmic socket reconstruction, and improved esthetic and motility results. Lipodermal grafts were an excellent alternative in our environment. We observed some complications with the different techniques, but only a few required surgical correction.

Gastrointestinal complications in liver transplant recipients: MITOS study

INTRODUCTION

Liver transplant recipients frequently suffer gastrointestinal (GI) complications but their prevalence and their influence on quality of life remain unknown.

OBJECTIVE

The objective of this study was to asses the prevalence, impact on quality of life, and management of GI complications in liver transplant recipients.

PATIENTS AND METHODS

This was an epidemiologic, cross-sectional, multicenter study. Four hundred seventeen liver recipients were recruited in 14 centers. A questionnaire was filled for every patient.

RESULTS

The median age of the patients was 55 years. The median time since transplantation was 4.1 +/- 4 years. Whereas 19.2% presented some GI disease before transplantation, 49.4% showed this type of complication after transplantation. Diarrhea was the most prevalent GI complication, and anorexia was the GI disorder that affected patients daily activities the most frequently. GI complications were more frequent among female patients, subjects with pretransplantation hiatal hernia, and those readmitted after transplantation. Of the patients with GI complications, 70.9% received pharmacological treatment (89.7% with gastric protectors). Immunosuppressive therapy was also modified because of GI complications. Immunosuppressive drug dose was reduced in 18.1%, transiently stopped in 3.4%, and definitively stopped in 3.4% of cases. The drug most frequently changed was mycophenolate mofetil: dose reduction, 23.6%; transient withdrawal, 5.7%; and definitive withdrawal, 6.6%.

CONCLUSIONS

The prevalence of GI complications in the liver transplant population was approximately 50%. GI complications showed a significant impact on the quality of life of the patients. They were related to female gender, to pretransplantation GI pathology, and posttransplantation hospital admission. These complications were frequently managed with pharmacological therapy or with changes in immunosuppressive therapy.

Evaluation of six pesticides leaching indexes using field data of herbicide application in Casablanca Valley, Chile

A field study was performed to evaluate the accuracy of six pesticide screening leaching indexes for herbicide movement. Adsorption, dissipation and soil movement were studied in a vineyard in a sandy loam soil during 2005 season. Simazine, diuron, pendimethalin, oxyfluorfen and flumioxazin were applied to bare soil at rates commonly used, and their soil concentrations throughout soil profile were determined at 0, 10, 20, 40 and 90 days after application (DAA). Herbicides were subjected to two pluviometric regimens, natural field condition and modified conditions (plus natural rainfall 180 mm). Leaching indexes utilized were: Briggs's Rf, Hamaker's Rf, LEACH, LPI, GUS and LIX. Simazine reached 120 cm, diuron 90 cm, flumioxazin 30 cm soil depth respectively. Pendimethalin and oxyfluorfen were retained up to 5 cm. None of the herbicides leaching was affected by rainfall regimen. Only flumioxazin field dissipation was clearly affected by pluviometric condition. The best representation of the herbicide soil depth movement and leaching below 15 cm soil depth were: Hamaker's Rf < Briggs's Rf < GUS < LPI, < LEACH < LIX. Field results showed a good correlation between herbicides K(d) and their soil depth movement and mass leached below 15 cm soil depth.

Long-term results for liver transplantation from non-heart-beating donors maintained with chest and abdominal compression-decompression

INTRODUCTION

The aim of this study was to evaluate long-term results after liver transplantation from non-heart-beating donors (NHBD) using the method of chest and abdominal compression-decompression to maintain donors.

METHODS

From December 1995 to November 2004, 10 NHBD were identified and maintained by means of the method of chest and abdominal compression-decompression until family and judicial permission were granted. Nine donors were Maastricht type II and one was type IV.

RESULTS

The mean age of donors was 40.5 years and the mean time under cardiopulmonary resuscitation (CPR) was 80 minutes. Orthotopic liver transplantation (OLT) was performed using these 10 liver grafts after a mean cold ischemia time of 561.5 minutes. All patients developed good posttransplant function, except for one patient who presented with primary nonfunction corrected with retransplantation. This complication was directly related to a long CPR time (P < .01). After a mean follow-up of 57 months, only one patient died from a hepatitis C virus (HCV) recurrence. The rest of the patients have maintained good graft function over time.

CONCLUSIONS

NHBD maintained with the method of chest and abdominal compression-decompression are a valid choice to increase the donor pool. Liver transplantation using these grafts has proven good long-term results, comparable to their heart-beating counterparts.

Benefits of recombinant activated factor VII in complicated liver transplantation

INTRODUCTION

Recombinant activated factor VII (rFVIIa, NovoSeven, NovoNordiskA/S, Bagsvaerd, Denmark) has shown benefits in hemophilic patients and recently in transplant recipients. This study presents our experiences with rFVIIa in complicated liver transplant recipients.

METHODS

From May 2001 to August 2004, rFVIIa was administered to 7 patients undergoing liver transplantation. All treatments were made on emergency bases, except for 1 case with hemophilia A, who received prophylactic treatment. The drug was delivered when severe bleeding with coagulopathy persisted despite the usual treatment with blood products. The drug doses were 60-90 mug/kg; the results were evaluated clinically and analytically.

RESULTS

Seven patients undergoing liver transplantation were treated with FVIIa. Mean prothrombin times before and after treatment were 17.5 and 10.9 seconds, respectively, with a mean reduction of 7.2 seconds (P = .03). Mean thromboplastin times before and after treatment were 38.1 and 29.4 seconds, respectively, with a mean reduction of 8.7 seconds (P = .034). The average dose was 83.6 mug/kg, leading to decreased consumption of blood products (P < .01). In all cases, rFVIIa allowed sufficient hemostasis to carry on definitive treatment. There was no mortality in this series.

CONCLUSIONS

These results provide new evidence on the potential benefits of rFVIIa in liver transplantation, especially for rescue therapy in cases of severe bleeding.

Steroid-free immunosuppression for pancreas-after-liver transplantation

Simultaneous pancreas-kidney transplantation is presently a well-accepted procedure for patients with type 1 diabetes mellitus and renal failure. However, experiences with combined pancreas and liver transplantation are scarce, a few data are available about the best immunosuppression for these patients. We report our experience with two patients who received a pancreas after liver transplantation for long-standing insulin-dependent diabetes mellitus, with steroid-free immunosuppression based on daclizumab, tacrolimus, and mycophenolate mofetil. Short- and long-term evolution was uneventful. Currently, both patients are insulin free with appropriate metabolic control after 12 and 6 months follow-up. Considering our preliminary results, we suggest a steroid-free immunosuppressive regimen as an option for pancreas-after-liver transplantation.

Laboratory study of inocula production for composting processes

Six ligno-cellulolytic fungi were tested regarding to examine their capability to grow on agricultural wastes and produce inocula for composting. Two residues were used: pepper plant wastes and almond shell residues. Results showed the latter as the most adequate substrate for growth of fungi tested. On the contrary, Trichoderma koningii, as well as HLC1 and HLC3, both fungi isolated from almond shell wastes, were able to persist in pepper plant wastes. Modifications of aeration and pH significantly influenced growth of Coriolus versicolor, HLC1 and Phanerochaete. flavido alba and P. flavido alba and Phlebia radiata, respectively, while P. flavido alba was the only microorganism whose growth was not significantly altered by temperature. In competitive assays, where fungi were growth together with other species, growth of both microorganisms isolated from almond shell residues, HLC1 and HLC3, were stimulated while T. koningii showed the better results in sterile conditions.

Liver transplantation from maastricht category 2 non-heart-beating donors: a source to increase the donor pool?

INTRODUCTION

The demand for liver transplantation has increasingly exceeded the supply of cadaver donor organs. Non-heart-beating donors (NHBDs) may be an alternative to increase the cadaver donor pool. The outcome of 20 liver transplants from Maastricht category 2 NHBD was compared with that of 40 liver transplants from heart-beating donors (HBDs). After unsuccessful cardiopulmonary resuscitation (CPR), cardiopulmonary support with simultaneous application of chest and abdominal compression (CPS; n = 6) or cardiopulmonary bypass (CPB; n = 14) was used to maintain the donors.

RESULTS

At a minimum follow-up of 2 years, actuarial patient and graft survival rates with livers from Maastricht category 2 NHBD were 80% and 55%, respectively. Transplantation of organs from these donors was associated with a significantly higher incidence of primary nonfunction, biliary complications, and more severe initial liver dysfunction compared with organs from HBDs. The graft survival rates was 83% for livers from NHBDs preserved with CPS and 42% in those maintained with CPB.

Liver transplantation from maastricht category 2 non-heart-beating donors: a source to increase the donor pool?

INTRODUCTION

The demand for liver transplantation has increasingly exceeded the supply of cadaver donor organs. Non-heart-beating donors (NHBDs) may be an alternative to increase the cadaver donor pool. The outcome of 20 liver transplants from Maastricht category 2 NHBD was compared with that of 40 liver transplants from heart-beating donors (HBDs). After unsuccessful cardiopulmonary resuscitation (CPR), cardiopulmonary support with simultaneous application of chest and abdominal compression (CPS; n = 6) or cardiopulmonary bypass (CPB; n = 14) was used to maintain the donors.

RESULTS

At a minimum follow-up of 2 years, actuarial patient and graft survival rates with livers from Maastricht category 2 NHBD were 80% and 55%, respectively. Transplantation of organs from these donors was associated with a significantly higher incidence of primary nonfunction, biliary complications, and more severe initial liver dysfunction compared with organs from HBDs. The graft survival rates was 83% for livers from NHBDs preserved with CPS and 42% in those maintained with CPB.

Retransplantation for hepatitis c–related cirrhosis under long-term pegylated interferon therapy

INTRODUCTION

Because of an increased organ shortage, one of the most controversial questions is whether hepatic retransplantation should be offered to transplant recipients with hepatitis C virus (HCV)-related graft failure because of their worse survival and the inevitable denial of other patients to access to primary transplantation. The objective of the present study was to review our experience with HCV-infected transplant recipients undergoing re-orthotopic liver transplantation (OLT) for HCV graft cirrhosis and receiving pegylated interferon and ribavirin on a prophylactic basis.

RESULTS

With a median follow-up of 26 months, all 5 patients are alive with stable graft function. Four patients are still receiving pegylated interferon at a mean duration of 20 months (range, 15-32 months). Although none of the patients has cleared HCV RNA by polymerase chain reaction the mean serum levels have decreased significantly when compared with pre-retransplantation amounts. One year after re-OLT, both grade and fibrosis stage had significantly decreased; the rate of post-retransplantation fibrosis progression was significantly lower than that pre-retransplantation (3.4 +/- 0.2 vs 0.6 +/- 0.3; P <.05).

Discriminative capacity of calcaneal quantitative ultrasound and of osteoporosis and fracture risk factors in postmenopausal women with osteoporotic fractures

Bone fragility fractures constitute the principal complication of osteoporosis. The identification of individuals at high risk of sustaining osteoporotic fractures is important for implementing preventive measures. The purpose of this study is to analyze the discriminative capacity of a series of osteoporosis and fracture risk factors, and of calcaneal quantitative ultrasound (QUS), in a population of postmenopausal women with a history of osteoporotic fracture. A cross-sectional analysis was made of a cohort of 5195 women aged 65 or older (mean +/- SD: 72.3 +/- 5.4 years) seen in 58 primary care centers in Spain. A total of 1042 women (20.1%) presented with a history of osteoporotic fracture. Most fractures (93%) were non-vertebral. Age-adjusted odds ratios corresponding to each decrease in one standard deviation of the different QUS parameters ranged from 1.47 to 1.55 (P < 0.001) for fractures. The age-adjusted multivariate analysis yielded the following risk factors independently associated with a history of osteoporotic fracture: number of fertile years, a family history of fracture, falls in the previous year, a history of chronic obstructive airway disease, the use of antiarrhythmic drugs, and a low value for any of the QUS parameters. The area under the receiver operating characteristic curve of the best model was 0.656. In summary, a series of easily assessable osteoporotic fracture risk factors has been identified. QUS was shown to discriminate between women with and without a history of fracture, and constitutes a useful tool for assessing fracture risk. Various of the vertebral and hip fracture risk factors frequently cited in North American and British populations showed no discriminative capacity in our series--thus suggesting that such factors may not be fully applicable to our population and/or to the predominant type of fractures included in the present study.

Physiology of exopolysaccharide production by Azotobacter vinelandii from 4-hydroxybenzoic acid

The relationship between exopolysaccharide (EPS) production by Azotobacter vinelandii ATCC 12837 from 4-hydroxybenzoic acid as sole carbon source and other physiological parameters was investigated. In relation to growth, Azotobacter needed more time in 4-hydroxybenzoic acid to reach levels of biomass similar to those obtained when sugars were used, although the phenolic compound led to a more extensive exponential phase. The encystment process was initiated after cells had grown for 24 h, in which small amounts of EPS were synthesized and poly-beta-hydroxybutyrate (PHB) accumulation began. Both polymers, EPS and PHB, showed a similar evolution with time, as well as the formation of cysts, which points out the existence of a relation between these parameters. This was corroborated by a statistical study, in which significant correlations (P<0.05) were observed when each parameter was compared to the two others.

Flutamide-induced hepatotoxicity: report of a case series

OBJECTIVE

To evaluate the characteristics of flutamide induced hepatotoxicity.

MATERIAL AND METHODS

In this retrospective study we have analyzed all cases of flutamide hepatotoxicity submitted to the Andalucian Registry of drug-induced liver disease. Data were collected using a structured reporting form. Causality assessment was performed using two clinical scales: the standard CIOMS scale and the recently developed María and Victorino scale.

RESULTS

Nine of 185 patients (4.9%) were identified. In 8 male patients, mean age 75 years (range 65-83), flutamide was indicated for palliative therapy of disseminated prostatic carcinoma, and in one young female (14 years) was given for the treatment of facial hirsutism. The mean duration of the flutamide therapy was 151 days (range 4-443). All patients presented with overt liver injury, the most frequent features being asthenia, anorexia, weight loss, nausea, vomiting and jaundice. No patient showed hypersensitivity features. In two patients (22%) the hepatic damage evolved to fulminant liver failure, one of them undergoing a liver transplantation and the other subsequently died. An additional patient died of a non-hepatic related cause when his liver function was improving. Causality assessment by the two clinical scales did not exclude any case, but the two patients who died where classified as unlikely by the María and Victorino scale.

CONCLUSIONS

Flutamide can induce severe acute hepatitis, probably due to an idiosyncratic metabolic mechanism. Liver tests monitoring should probably be mandatory during the first months of flutamide therapy and the drug withdrawn if transaminases began to increase.

Influence of nutritional and environmental factors on polysaccharide production by Azotobacter vinelandii cultured on 4-hydroxybenzoic acid

The capacity of 4-hydroxybenzoic acid to support exopolysaccharide (EPS) biosynthesis was investigated. Carbon source concentration, nitrogen supplementation, and other nutritional and environmental factors were optimized to obtain maximal EPS recovery. Higher EPS yields were obtained in nitrogen-free media amended with 20-30 mM 4-hydroxybenzoic acid. In general, modifications in inorganic salt concentration did not alter EPS production, except in the case of magnesium ions. Increased levels of this cation were correlated to greater EPS yields. Production was strongly influenced by certain environmental factors. Optimal values of 34 degrees C, 80 rpm and neutral or slightly basic conditions were selected. Under these conditions, more than 25% of the carbon source supplied was converted to EPS and the production was improved about 42% in comparison to that observed in the initial media.

A comparison between two induction regimes for the interferon treatment of chronic hepatitis C. Response related factors

Treatment of chronic hepatitis C with alfa interferon for 6 months achieves sustained responses in 15-25% of the patients. The initial induction with higher doses and the prolongation of treatment can improve the results. A randomized, prospective study was carried out to compare the efficacy of a short term induction schedule of interferon alfa-2b (group A) versus a long term one (group B). 106 patients with chronic hepatitis C were included: 54 received 5 megaunits tiw for 8 weeks and 52 for 16 weeks; afterwards, interferon was reduced to 3 megaunits up to 9 months. The percentage of sustained responses, transient responses and non responses were 18.5%, 24% and 57.4% in group A and 23.1%, 28.8% and 48.1% in group B (NS). The following factors were related to a poor response in the univariate analysis: an increase of serum iron levels, ferritin, Gamma-GT and bilirubin, anti-nuclear antibody positivity, presumed non-parenteral infection, an AST/ALT ratio greater than 0.75, a higher Knodell's index and a greater necrosis and fibrosis score. The multivariate analysis revealed that elevated serum iron and ferritin and anti-nuclear antibody positivity had an independent predictive value related to a non response. Our results appear to suggest that an induction with higher doses and the treatment over nine months are more efficient than the classic schedule. The prolongation of the induction period does not provide additional advantages.

[Body temperature variations during laparoscopic cholecystectomies]

OBJECTIVE

To study changes over time in body temperature related to insufflation of CO2.

PATIENTS AND METHOD

Fifty patients were randomly assigned to 2 groups of 25 to undergo cholecystectomy by either laparoscopy or laparotomy. Total intravenous anesthesia with propofol, pancuronium and fentanyl was used in both groups. Ventilation was maintained at 0.5 FiO2. Central temperature was continuously measured by a distal esophageal thermometer and results were recorded every 10 minutes in both groups. All operations lasted approximately 80 min.

RESULTS

We found that temperature gradually decreased over time in both groups. In the laparotomy group the decrease reached 0.20 degree C (SD 0.03) at 80 min. During laparoscopy the temperature decrease was 0.43 degree C (SD 0.04) for the same time period. The differences were statistically significant. We observed no pathophysiologic repercussions associated with these results.

CONCLUSIONS

Laparoscopic surgery, even when the abdominal cavity is not exposed to room air, induces a loss of temperature that is greater than that of laparotomy, because of insufflation of CO2 at 4 degrees C. The decrease was 0.4 degree C for every 50 l of CO2 insufflated during the study.

[Chronic hepatitis C virus infection associated with anti-LKM 1]

A case of chronic hepatitis in a 20-year-old patient in whom hepatitis C virus infection markers and type 1 liver and kidney antimicrosome antibodies (anti-LKM 1) were detected, thereby allowing diagnosis of autoimmune type 2b hepatitis, is reported. The different types of autoimmune hepatitis (AIH) and the type 2a and 2b AIH are discussed as are the rejection of this terminology by some authors followed by their proposals and the therapeutic strategy to be used in these patients.

[Pleural empyema as a complication of the sclerotherapy of esophageal varices]

We present three patients developing pleural empyema after sclerotherapy of esophagic varixes. In all of them, the presence of persistent fever syndrome following the sclerotherapy, along with radiological images of pleural overflow, were the starting point of the patient's study. In the emergency esophagogrames, the extravasation of contrast outside the esophagus could not be confirmed. The treatment, which must be started as soon as possible, was based in conservative measures (drainage, antibiotics and a proper nutrition), given the poor general condition of these patients. Despite all these measures, the prognosis is poor, with two of the three patients dying despite the administration of the treatment. In conclusion, although its frequency is very low, pleural empiema is an extremely severe complication of the sclerotherapy of esophagic varixes. If this complication is suspected, the prognosis depends on a treatment that must be started as soon as possible.

[Caroli's disease. Presentation of 8 cases studied with ERCP]

Eight patients with Caroli's Disease are presented, studied by Endoscopic Retrograde Cholangiopancreatography (ERCP) from January 1976 through January 1990. In this period of time 1,525 procedures were carried out, this entity thus representing 0.52% of patients submitted to ERCP in our population. Six patients were females, being female: male ratio 3:1. Mean age was 52 years (range: 40-75). All patients presented a clinical history of recurring episodes of abdominal pain and/or crisis of cholangitis. In the ERCP carried out in these eight patients, cystic dilatation of intrahepatic left lobe bile ducts were confirmed in five patients, dilatation generalized to both lobes in two, and affecting exclusively the right lobe in one patient.