Alternative forms of portal vein revascularization in liver transplant recipients with complex portal vein thrombosis

BACKGROUND & AIMS

Complex portal vein thrombosis (PVT) is a challenge in liver transplantation (LT). Extra-anatomical approaches to portal revascularization, including renoportal (RPA), left gastric vein (LGA), pericholedochal vein (PCA), and cavoportal (CPA) anastomoses, have been described in case reports and series. The RP4LT Collaborative was created to record cases of alternative portal revascularization performed for complex PVT.

METHODS

An international, observational web registry was launched in 2020. Cases of complex PVT undergoing first LT performed with RPA, LGA, PCA, or CPA were recorded and updated through 12/2021.

RESULTS

A total of 140 cases were available for analysis: 74 RPA, 18 LGA, 20 PCA, and 28 CPA. Transplants were primarily performed with whole livers (98%) in recipients with median (IQR) age 58 (49-63) years, model for end-stage liver disease score 17 (14-24), and cold ischemia 431 (360-505) minutes. Post-operatively, 49% of recipients developed acute kidney injury, 16% diuretic-responsive ascites, 9% refractory ascites (29% with CPA, p <0.001), and 10% variceal hemorrhage (25% with CPA, p = 0.002). After a median follow-up of 22 (4-67) months, patient and graft 1-/3-/5-year survival rates were 71/67/61% and 69/63/57%, respectively. On multivariate Cox proportional hazards analysis, the only factor significantly and independently associated with all-cause graft loss was non-physiological portal vein reconstruction in which all graft portal inflow arose from recipient systemic circulation (hazard ratio 6.639, 95% CI 2.159-20.422, p = 0.001).

CONCLUSIONS

Alternative forms of portal vein anastomosis achieving physiological portal inflow (i.e., at least some recipient splanchnic blood flow reaching transplant graft) offer acceptable post-transplant results in LT candidates with complex PVT. On the contrary, non-physiological portal vein anastomoses fail to resolve portal hypertension and should not be performed.

IMPACT AND IMPLICATIONS

Complex portal vein thrombosis (PVT) is a challenge in liver transplantation. Results of this international, multicenter analysis may be used to guide clinical decisions in transplant candidates with complex PVT. Extra-anatomical portal vein anastomoses that allow for at least some recipient splanchnic blood flow to the transplant allograft offer acceptable results. On the other hand, anastomoses that deliver only systemic blood flow to the allograft fail to resolve portal hypertension and should not be performed.

Abdominal normothermic regional perfusion in controlled donation after circulatory determination of death liver transplantation: Outcomes and risk factors for graft loss

Postmortem normothermic regional perfusion (NRP) is a rising preservation strategy in controlled donation after circulatory determination of death (cDCD). Herein, we present results for cDCD liver transplants performed in Spain 2012-2019, with outcomes evaluated through December 31, 2020. Results were analyzed retrospectively and according to recovery technique (abdominal NRP [A-NRP] or standard rapid recovery [SRR]). During the study period, 545 cDCD liver transplants were performed with A-NRP and 258 with SRR. Median donor age was 59 years (interquartile range 49-67 years). Adjusted risk estimates were improved with A-NRP for overall biliary complications (OR 0.300, 95% CI 0.197-0.459, p < .001), ischemic type biliary lesions (OR 0.112, 95% CI 0.042-0.299, p < .001), graft loss (HR 0.371, 95% CI 0.267-0.516, p < .001), and patient death (HR 0.540, 95% CI 0.373-0.781, p = .001). Cold ischemia time (HR 1.004, 95% CI 1.001-1.007, p = .021) and re-transplantation indication (HR 9.552, 95% CI 3.519-25.930, p < .001) were significant independent predictors for graft loss among cDCD livers with A-NRP. While use of A-NRP helps overcome traditional limitations in cDCD liver transplantation, opportunity for improvement remains for cases with prolonged cold ischemia and/or technically complex recipients, indicating a potential role for complimentary ex situ perfusion preservation techniques.

Immediate post-operative complications (I): Post-operative bleeding; vascular origin: Thrombosis pancreatitis

Simultaneous pancreas-kidney transplantation is the treatment of choice for insulin-dependent diabetes that associates end-stage diabetic nephropathy, since it achieves not only a clear improvement in the quality of life, but also provides a long-term survival advantage over isolated kidney transplant. However, pancreas transplantation still has the highest rate of surgical complications among organ transplants. More than 70% of early graft losses are attributed to technical failures, that is, to a non-immunological cause. The so-called technical failures include graft thrombosis, bleeding, infection, pancreatitis, anastomotic leak and pancreatic fistula. Pancreatic graft thrombosis leads these technical complications as the most frequent cause of early graft loss. Currently most recipients receive postoperative anticoagulation with the aim of reducing the rate of thrombosis. Hemoperitoneum in the early postoperative period is a frequent cause of relaparotomy, but it is not usually associated with graft loss. The incidence of hemoperitoneum is clearly related to the use of anticoagulation in the postoperative period. Post-transplant pancreatitis is another cause of early postoperative complications, less frequent than the previous. In this review, we analyze the most common surgical complications that determine pancreatic graft losses.

Normothermic regional perfusion vs. super-rapid recovery in controlled donation after circulatory death liver transplantation

BACKGROUND & AIMS

Although there is increasing interest in its use, definitive evidence demonstrating a benefit for postmortem normothermic regional perfusion (NRP) in controlled donation after circulatory death (cDCD) liver transplantation is lacking. The aim of this study was to compare results of cDCD liver transplants performed with postmortem NRP vs. super-rapid recovery (SRR), the current standard for cDCD.

METHODS

This was an observational cohort study including all cDCD liver transplants performed in Spain between June 2012 and December 2016, with follow-up ending in December 2017. Each donor hospital determined whether organ recovery was performed using NRP or SRR. The propensity scores technique based on the inverse probability of treatment weighting (IPTW) was used to balance covariates across study groups; logistic and Cox regression models were used for binary and time-to-event outcomes.

RESULTS

During the study period, there were 95 cDCD liver transplants performed with postmortem NRP and 117 with SRR. The median donor age was 56 years (interquartile range 45-65 years). After IPTW analysis, baseline covariates were balanced, with all absolute standardised differences <0.15. IPTW-adjusted risks were significantly improved among NRP livers for overall biliary complications (odds ratio 0.14; 95% CI 0.06-0.35, p <0.001), ischaemic type biliary lesions (odds ratio 0.11; 95% CI 0.02-0.57; p = 0.008), and graft loss (hazard ratio 0.39; 95% CI 0.20-0.78; p = 0.008).

CONCLUSIONS

The use of postmortem NRP in cDCD liver transplantation appears to reduce postoperative biliary complications, ischaemic type biliary lesions and graft loss, and allows for the transplantation of livers even from cDCD donors of advanced age.

LAY SUMMARY

This is a propensity-matched nationwide observational cohort study performed using livers recovered from donors undergoing cardiac arrest provoked by the intentional withdrawal of life support (controlled donation after circulatory death, cDCD). Approximately half of the livers were recovered after a period of postmortem in situ normothermic regional perfusion, which restored warm oxygenated blood to the abdominal organs, whereas the remainder were recovered after rapid preservation with a cold solution. The study results suggest that the use of postmortem normothermic regional perfusion helps reduce rates of post-transplant biliary complications and graft loss and allows for the successful transplantation of livers from older cDCD donors.

The Southampton Consensus Guidelines for Laparoscopic Liver Surgery: From Indication to Implementation

OBJECTIVE

The European Guidelines Meeting on Laparoscopic Liver Surgery was held in Southampton on February 10 and 11, 2017 with the aim of presenting and validating clinical practice guidelines for laparoscopic liver surgery.

BACKGROUND

The exponential growth of laparoscopic liver surgery in recent years mandates the development of clinical practice guidelines to direct the speciality's continued safe progression and dissemination.

METHODS

A unique approach to the development of clinical guidelines was adopted. Three well-validated methods were integrated: the Scottish Intercollegiate Guidelines Network methodology for the assessment of evidence and development of guideline statements; the Delphi method of establishing expert consensus, and the AGREE II-GRS Instrument for the assessment of the methodological quality and external validation of the final statements.

RESULTS

Along with the committee chairman, 22 European experts; 7 junior experts and an independent validation committee of 11 international surgeons produced 67 guideline statements for the safe progression and dissemination of laparoscopic liver surgery. Each of the statements reached at least a 95% consensus among the experts and were endorsed by the independent validation committee.

CONCLUSION

The European Guidelines Meeting for Laparoscopic Liver Surgery has produced a set of clinical practice guidelines that have been independently validated for the safe development and progression of laparoscopic liver surgery. The Southampton Guidelines have amalgamated the available evidence and a wealth of experts' knowledge taking in consideration the relevant stakeholders' opinions and complying with the international methodology standards.

Safety and Efficacy of Early Everolimus When Calcineurin Inhibitors Are Not Recommended in Orthotopic Liver Transplantation

Our aim was to study the safety and efficacy of immunosuppression with everolimus (EVL) within the 1st month after orthotopic liver transplantation (LT) when calcineurin inhibitors are not recommended. For this purpose, 28 recipients who had been treated with EVL within the 1st month after adult LT were eligible to enter in a retrospective multicenter study. Patients were followed up for 12 months after LT. EVL therapy was initiated at a median of 14 days (range, 4-24) after LT. The reason for early EVL was neurotoxicity in 14 cases, renal dysfunction in 12, and acute cellular rejection combined with renal impairment in 2. In 23 patients, immunosuppression was EVL + mycophenolate mofetil/mycophenolate sodium + steroids, and EVL + tacrolimus + steroids/mycophenolate sodium was used in 4 cases. Neurotoxicity disappeared in all patients. Renal function in patients with renal impairment improved from a median of 32 mL/min/1.73 m² at the moment of implementation of EVL to 62 mL/min/1.73 m² at 1 year. Four patients (14.3%) developed acute cellular rejection. We observed incisional hernia in 4 patients (14.3%), hematologic complications in 6 (21.4%), proteinuria in 2 (7.1%), edema and/or effusions in 8 (28.6%), and dyslipidemia in 12 (42.8%). No arterial complications were observed. EVL was withdrawn in 5 patients during the 1st year after LT. One-year patient survival was 92.7%. In conclusion, use of EVL within the 1st month after LT when calcineurin inhibitors are not recommended seems to be an effective therapeutic option with an acceptable safety profile.

"Very early" intrahepatic cholangiocarcinoma in cirrhotic patients: should liver transplantation be reconsidered in these patients?

A retrospective cohort multicenter study was conducted to analyze the risk factors for tumor recurrence after liver transplantation (LT) in cirrhotic patients found to have an intrahepatic cholangiocarcinoma (iCCA) on pathology examination. We also aimed to ascertain whether there existed a subgroup of patients with single tumors ≤2 cm ("very early") in which results after LT can be acceptable. Twenty-nine patients comprised the study group, eight of whom had a "very early" iCCA (four of them incidentals). The risk of tumor recurrence was significantly associated with larger tumor size as well as larger tumor volume, microscopic vascular invasion and poor degree of differentiation. None of the patients in the "very early" iCCA subgroup presented tumor recurrence compared to 36.4% of those with single tumors >2 cm or multinodular tumors, p = 0.02. The 1-, 3- and 5-year actuarial survival of those in the "very early" iCCA subgroup was 100%, 73% and 73%, respectively. The present is the first multicenter attempt to ascertain the risk factors for tumor recurrence in cirrhotic patients found to have an iCCA on pathology examination. Cirrhotic patients with iCCA ≤2 cm achieved excellent 5-year survival, and validation of these findings by other groups may change the current exclusion of such patients from transplant programs.

Negative pressure therapy as palliative treatment for a colonic fistula

Colonic fistulas in an open wound are always a challenge for colorectal surgeons, and this report provides a technique for the appropriate management of these cases. We communicate the use of a negative pressure dressing therapy as part of the palliative care for a patient following the development of an enterocutaneous fistula. The use of this therapy allowed us to keep the patient clean and comfortable during the last few days of his life.

[Solid organ transection. Open and laparoscopic surgery]

Recent advances in liver surgery have reduced post-hepatectomy mortality to less than 5% in most units specialized in hepato-pancreatic-biliary surgery. Possibly, the single most important factor contributing to these improved results has been the reduction in intraoperative bleeding during liver parenchymal transection. Liver transection is the most risky part of the intervention due to the risk of massive hemorrhage. Some technological advances and refinements to the surgical technique have contributed to making this critical phase of liver surgery safer. Among these advances, the most notable are detailed knowledge of the surgical anatomy of the liver, vascular control techniques and methods of liver parenchymal transection. The present review describes current transection techniques, as well as their advantages and disadvantages. Until there is solid evidence on the best method, the choice of technique and instrument for liver transection depends mainly on the surgeon's personal preference. Nevertheless, some factors can influence the choice of method, such as the surgeon's experience, anesthetic management, type of hepatectomy (central, peripheral), type of approach (open, laparoscopic), quality of the liver (normal, cirrhotic, steatotic) and the availability of the instruments in the center.

True impact of the indication of cirrhosis and the MELD on the results of liver transplantation

Our Aim was to determine the impact of cirrhosis and the preoperative MELD score on the immediate postoperative mortality and hospital stay as well as survival at 1, 5, and 8 years in liver transplantation.

MATERIALS AND METHODS

Transplanted cirrhotic patients were selected who did not display some of the main known risk factors affecting recipient. Donor and surgical technique were included in this analysis. These exclusion criteria for recipient factors were emergency transplants and retransplants; for donor factors, age over 60 years, ischemia time over 10 hours, and moderate or severe steatosis on back-bench biopsy; and for surgery, prior complex upper abdominal surgery (mainly derivative and gastroduodenal surgery). Among 340 total liver transplants including 16 retransplants performed from March 1997 to December 2005, 197 patients met the selection criteria. The mean age of the recipients was 52 years (17-67) and the donors, 39 years (11-60). The transplant indication was cirrhosis in all cases: HCV in 69 cases (35%); alcohol in 55 (28%); hepatocarcinoma in 38 (19%); HBV in 19 (10%); PBC in 8 (4%), and other etiologies in 8 cases (4%). The MELD scores were divided as group 1, <10 points (33 cases = 17%); group 2, 10 to 18 points (136 cases = 69%); and group 3, >18 points (28 cases = 14%). The statistical analysis was performed with SPSS 11.0.

RESULTS

Postoperative mortality (up to 3 months) was 16 cases (8%). The median ICU and hospital stays were 3 and 13.5 days, respectively. Overall survivals at 1, 5, and 8 years were 89%, 80%, and 77%, respectively. The survival for the same periods according to MELD group was 97%, 97%, and 97% for group 1; 87%, 76%, and 72% for group 2; and 85%, 81%, and 81% for group 3 (P = NS). The survival according to the three main indications at 1, 5, and 8 years was: HCV, 91%, 80%, and 80%; alcohol, 87%, 80%, and 71%; and hepatocarcinoma, 84%, 80%, and 80% (P = NS). No significant differences were observed among early deaths between MELD groups or transplant indications.

CONCLUSIONS

In a favorable liver transplant setting including acceptable donors, absence of prior complex abdominal surgery in the recipient, and nonemergency transplants, neither the cause of the cirrhosis nor its severity, as measured preoperatively by the MELD, were predictive of early postoperative death or long-term survival.

Influence of degree of hepatic steatosis on graft function and postoperative complications of liver transplantation

The aim of this study was to evaluate the impact on initial graft function of the degree of steatosis detected in the back-table biopsy, and its repercussion on the clinical results of the transplant (early posttransplant mortality and morbidity). We undertook a retrospective analysis of 300 liver transplants performed at our center from 1997 to 2004. A wedge liver biopsy was done routinely during back-table surgery (available in 294 transplants). The degree of steatosis was classified as: S0-no steatosis, 201 transplants; S1-mild steatosis (<30%), 58 transplants; S2-moderate steatosis (30% to 60%), 18 transplants; and S3-severe steatosis (>60%), 17 transplants. The ischemia-reperfusion (I/R) injury, based on the maximum mean peak aspartate transferase in the first 72 posttransplant hours, tended to be greater as the degree of graft steatosis increased: S0, 1316; S1, 1985; S2, 2446; and S3, 2955 (P < .005 between S0 and S3). This greater initial hepatic dysfunction was correlated in the group with severe steatosis with a higher rate of severe renal failure requiring hemofiltration/hemodialysis: S0, 9%; S1, 15%; S2, 11%; and S3, 41% (P < .001); as well as with a higher early mortality (90 days): S0, 10%; S1, 21%; S2, 11%; and S3, 41% (P < .001). The Kaplan-Meier survival curve showed a significant difference (log-rank and Breslow) between the group with severe steatosis and the group with no steatosis (P = .002). We conclude that the degree of liver graft steatosis is an important determinant of I/R injury, although this progressive increase in the I/R injury with the degree of steatosis only had clinical repercussions in the case of severe steatosis.

Model for End-Stage Liver Disease Score-Based Allocation of Donors for Liver Transplantation: A Spanish Multicenter Experience

BACKGROUND

Prioritizing the liver transplant waiting list (WL) is subject to great variability. We present the experience of four transplant centers in Andalusia (Southern Spain) with a new consensus model of WL management based on the Model for End-Stage Liver Disease (MELD) score.

METHODS

The initial criteria for local prioritizing were: a) cirrhosis with MELD score > or =24, and b) all hepatocellular carcinoma (HCC) admitted to the WL. Fourteen months later new criteria were established: a) cirrhosis with MELD score > or =18, and b) uninodular HCC between 3-5 cm or multinodular HCC (2-3 nodules <3 cm). Access to regional priority was scheduled after three months for patients with cirrhosis or six months for patients with HCC. We analyzed the WL mortality rate, posttransplant survival rate, and overall survival rate over three 14-month periods: A (before implementation of priority criteria), B (initial criteria), and C (current criteria).

RESULTS

Priority was given to 36% of recipients in period B and 47% in period C. The WL mortality rate (including removals from WL) was 12.9%, 12.9%, and 10.7% in periods A, B, and C, respectively. One-year graft survival was 79.7%, 72.6%, and 81.2% in the same periods. The overall one-year survival rate for new cases on the WL was 74.9% in period A, 68.6% in period B, and 82.2% in period C.

CONCLUSIONS

The allocation system and WL management with the current criteria resulted in lower waiting list mortality without reducing posttransplant survival, leading to better survival for all patients listed.

Transfusion Requirements During Liver Transplantation: Impact of a Temporary Portacaval Shunt

We evaluated the consumption of blood products during liver transplantation in cirrhotic patients association with the placement of a temporary portacaval shunt (TPCS).

PATIENTS AND METHODS

We retrospectively divided 349 cirrhotic patients transplanted in our unit between March 1997 and October 2005 into two groups: transplants without a TPCS (group I, 189 cases) and those with a TPCS (group II, 160 cases). In all cases, we preserved the inferior vena cava (piggyback). The dependent variables were consumption of blood-derived products (banked red cells, recovered red cells, fresh frozen plasma, platelets), surgery time, kidney function, intensive care unit stay, and hospital stay.

RESULTS

Consumption of blood products was significantly lower among patients who received a TPCS. In group II, no platelet transfusion was required in 54% of the patients, and no banked red cells in 12% compared with 18% and 3%, respectively, among group I patients (P < .005). The mean overall transplant procedure time was 74 minutes shorter in group II (361 minutes) compared with group I (435 minutes) (P < .001). The overall hospital stay was shorter among patients transplanted after TPCS.

CONCLUSION

Liver transplantation with a TPCS was accompanied by a reduction in the intraoperative use of blood-derived products, especially platelet transfusion. Among other advantages, this reduction resulted in a shorter posttransplant hospital stay.

Liver Transplant Results for Hepatocellular Carcinoma Applying Strict Preoperative Selection Criteria

INTRODUCTION

Liver transplantation is currently the best therapeutic option for small hepatocellular carcinoma (HC) in selected cirrhotic patients. The main aim of this study was to analyze the results of a recent series of liver transplant cirrhotic patients with small HC applying strict preoperative selection criteria.

PATIENTS AND METHODS

During a period of 6 years we performed 53 liver transplants with a final diagnosis of HC on cirrhosis. The selection criteria for liver transplantation (LT) by modern imaging techniques were the Milan criteria (TNM I and II of the modified classification).

RESULTS

Of the 53 patients, 44 (83%) were transplanted with preoperatively known HC, and 9 (17%) with incidental HC. The mean time on the waiting list was 74 +/- 62 days. Despite using strict selection criteria, 23 patients (43%) exceeded the Milan criteria in the specimen and 17 (32%) even exceeded the extended criteria of the UCSF. With a mean follow-up of 2 years, only two patients have developed recurrences. The overall survival at 1, 3, and 5 years was 80%, 70%, and 70%, respectively. The survival of patients that exceeded the Milan or USF criteria at 1, 3, and 5 years was 72% and 76%; 67% and 69%; 67% and 69%, respectively.

CONCLUSIONS

The results of liver transplantation for HC are excellent when applying strict preoperative selection criteria. The current imaging methods lead to a considerable infrastaging percentage (30% to 40%), extending the indications for liver transplant due to HC beyond the scope that clinical reports would justify.

Preoperative Factors and Models Predicting Mortality in Liver Transplantation

We analyzed preoperative factors related to postoperative mortality after liver transplantation among a cohort of 268 consecutive liver transplant patients over 6 years. We studied the impact of 10 recipient variables, 14 donor features, and three operative aspects. We also studied the correlation with death and survival using various predictive scores (Child, Cordoba Score, MELD, and UCLA). Univariate analysis showed that the factors with a significant association with postoperative mortality were the use of noradrenaline in the donor, total ischemia time (>12 hours), and transplant indication (hepatitis C virus versus the rest). Multivariate analysis of mortality showed the impact of female donor sex, recipients over >60 years, recipient albumin less than 2.8, and total graft ischemia time more than 12 hours. Univariate analysis of 1-year survival showed a statistically significant relation with D/R gender similarity, as well as donor GOT (>170) and GPT (>140) values. Multivariate analysis of 1-year survival showed donor GOT (>170) and donor/recipient gender similarity to be significant. Concerning the prediction models, Child-Pugh (AB versus C) best determined postoperative mortality (P < .006), MELD was predictive of 1-year survival (P < .03). The most important variables related to postoperative mortality were total ischemia time over 12 hours, recipient albumin less than 2.8, and age above 60 years. The variable with most impact on 1-year survival was the degree of graft hepatocyte lesion as determined by GOT. The Child-Pugh system is still the best indicator of postoperative mortality, although MELD may also be a good predictor of survival.

Spanish experience in liver transplantation for hilar and peripheral cholangiocarcinoma

OBJECTIVE

To assess the real utility of orthotopic liver transplantation (OLT) in patients with cholangiocarcinoma, we need series with large numbers of cases and long follow-ups. The aim of this paper is to review the Spanish experience in OLT for hilar and peripheral cholangiocarcinoma and to try to identify the prognostic factors that could influence survival.

SUMMARY BACKGROUND DATA

Palliative treatment of nondisseminated irresectable cholangiocarcinoma carries a zero 5-year survival rate. The role of OLT in these patients is controversial, due to the fact that the survival rate is lower than with other indications for transplantation and due to the lack of organs.

METHODS

We retrospectively reviewed 59 patients undergoing OLT in Spain for cholangiocarcinoma (36 hilar and 23 peripheral) over a period of 13 years. We present the results and prognostic factors that influence survival.

RESULTS

The actuarial survival rate for hilar cholangiocarcinoma at 1, 3, and 5 years was 82%, 53%, and 30%, and for peripheral cholangiocarcinoma 77%, 65%, and 42%. The main cause of death, with both types of cholangiocarcinoma, was tumor recurrence (present in 53% and 35% of patients, respectively). Poor prognosis factors were vascular invasion (P < 0.01) and IUAC classification stages III-IVA (P < 0.01) for hilar cholangiocarcinoma and perineural invasion (P < 0.05) and stages III-IVA (P < 0.05) for peripheral cholangiocarcinoma.

CONCLUSIONS

OLT for nondisseminated irresectable cholangiocarcinoma has higher survival rates at 3 and 5 years than palliative treatments, especially with tumors in their initial stages, which means that more information is needed to help better select cholangiocarcinoma patients for transplantation.

Liver transplantation for peripheral cholangiocarcinoma: Spanish experience

INTRODUCTION

Palliative treatment for nondisseminated unresectable peripheral cholangiocarcinoma (PCC) carries a 0% 5-year survival rate. The role of orthotopic liver transplantation (OLT) in these patients is controversial because the survival rate is lower than with other indications for transplantation and the lack of available donor organs. The aim of this paper was to review the Spanish experience in OLT for PCC to identify prognostic factors for survival.

METHODS

We retrospectively reviewed 23 patients undergoing OLT in Spain for PCC over a period of 13 years.

RESULTS

The actuarial survival rates were 77%, 65%, and 42% at 1, 3, and 5 years, respectively. The main cause of death was tumor recurrence (35%). Prognotic factors for an adverse outcome were pTNM classification (P<.05) in the univariate analysis and perineural invasion (P<.05) and stages III or IVA (P<.05) in the multivariate analysis.

CONCLUSIONS

OLT for nondisseminated irresectable PCC displays higher survival rates at 3 and 5 years than palliative treatments, especially for tumors in the initial stages, which means that more information is needed to help better select PCC patients for transplantation.

Liver transplantation for hilar cholangiocarcinoma: Spanish experience

INTRODUCTION

Palliative treatment for nondisseminated irresectable hilar cholangiocarcinoma (HCC) carries a 0% 5-year survival rate. The role of orthotopic liver transplantation (OLT) in these patients is controversial because the survival rate is lower than that for other indications for transplantation and the lack of available donor organs. The aim of this paper was to review the Spanish experience in OLT for HCC and identify prognostic factors for survival.

METHODS

We retrospectively reviewed 36 patients undergoing OLT for HCC over 13 years.

RESULTS

The actuarial survival rate at 1, 3, and 5 years was 82%, 53%, and 30%, respectively. The main cause of death was tumor recurrence (53%). In the univariate analysis, the factors for a poor prognosis were vascular invasion (P<.001) namely 0% survival at 3 years when present versus 63% and 35% at 3 and 5 years, respectively, when it was not; and stages III to IVA (P<.05), namely 15% survival at 5 years versus 47% for stages I to II. Lymph node and perineural invasion also reduce survival. In the multivariate analysis, the factors for poor prognosis included vascular invasion (P<.01) and stages III to IVA (P<.01).

CONCLUSION

OLT for nondisseminated irresectable HCC has higher survival rates at 3 and 5 years than palliative treatments, especially with initial stage tumors, which means that more information is needed to better select cholangiocarcinoma patients for transplantation.

Selection criteria for liver transplantation in early-stage hepatocellular carcinoma with cirrhosis: results of a multicenter study

Orthotopic liver transplantation (OLT) offers the only chance to eliminate both tumor and liver disease in patients with hepatocellular carcinoma (HCC) and cirrhosis. However, tumor progression while on the waiting list and recurrence after OLT are frequent. We undertook a large multicenter study to assess survival and related factors of recurrence after OLT. This retrospective study analyses data from 307 consecutive patients with HCC and cirrhosis treated with OLT between 1990 and 1997 in eight centers in Spain. OLT was indicated only for small (<5 cm) localized tumors. Five-year rates after OLT were 63% for survival, 58% for disease-free survival, and 21% for recurrence. Tumor diameter larger than 5 cm was associated with other tumor characteristics that were significant indicators of poor outcome (absence of capsule, three or more nodules, bilobularity, satellite nodules, and vascular invasion). However, in multivariate analysis, alpha fetoprotein (AFP) levels greater than 300 ng/mL (P = .04; P = .02) and macroscopic vascular invasion (P = .01; P = .0001) were the only factors independently associated with mortality and recurrence, respectively. OLT is indicated in patients with small HCCs who have low AFP levels and no macroscopic vascular invasion or extrahepatic disease. By increasing our ability for preoperative tumor imaging, we will achieve better selection of patients with HCC before OLT.

Use of the breast implant for liver graft malposition

Transplantation of a small liver into a large patient may cause problems with correct reperfusion of the graft because of torsion of the hepatic pedicle, leading to malfunction of the transplanted organ. We describe the case of a 60-year-old man with alcoholic cirrhosis and hepatitis B virus who received a small-sized liver graft. Owing to the lack of adequate reperfusion of the transplanted organ arising from pedicular kinking caused by disparate sizes, a breast implant was placed behind the graft as a means of support, thereby resolving the problem. The use of prosthetic materials for the correct placement of grafts with size incongruity is also discussed, and the literature is reviewed.

Characterization of a mammalian homolog of the GCN2 eukaryotic initiation factor 2alpha kinase

In eukaryotic cells, protein synthesis is regulated in response to various environmental stresses by phosphorylating the alpha subunit of the eukaryotic initiation factor 2 (eIF2alpha). Three different eIF2alpha kinases have been identified in mammalian cells, the heme-regulated inhibitor (HRI), the interferon-inducible RNA-dependent kinase (PKR) and the endoplasmic reticulum-resident kinase (PERK). A fourth eIF2alpha kinase, termed GCN2, was previously characterized from Saccharomyces cerevisiae, Drosophila melanogaster and Neurospora crassa. Here we describe the cloning of a mouse GCN2 cDNA (MGCN2), which represents the first mammalian GCN2 homolog. MGCN2 has a conserved motif, N-terminal to the kinase subdomain V, and a large insert of 139 amino acids located between subdomains IV and V that are characteristic of the known eIF2alpha kinases. Furthermore, MGCN2 contains a class II aminoacyl-tRNA synthetase domain and a degenerate kinase segment, downstream and upstream of the eIF2alpha kinase domain, respectively, and both are singular features of GCN2 protein kinases. MGCN2 mRNA is expressed as a single message of approximately 5.5 kb in a wide range of different tissues, with the highest levels in the liver and the brain. Specific polyclonal anti-(MGCN2) immunoprecipitated an eIF2alpha kinase activity and recognized a 190 kDa phosphoprotein in Western blots from either mouse liver or MGCN2-transfected 293 cell extracts. Interestingly, serum starvation increased eIF2alpha phosphorylation in MGCN2-transfected human 293T cells. This finding provides evidence that GCN2 is the unique eIF2alpha kinase present in all eukaryotes from yeast to mammals and underscores the role of MGCN2 kinase in translational control and its potential physiological significance.

[Hepatocellular carcinoma associated to porphyria cutanea tarda and hepatitis C virus infection without cirrhosis]

The molecular basis of porphyria cutanea tarda is defective activity of hepatic uroporphyrinogen decarboxylase. A common characteristic is liver dysfunction than goes from cirrhosis to hepatocellular carcinoma. A high prevalence of hepatitis C virus markers has been demonstrated. We study a patient with PCT and hepatitis C virus markers that finally develops to hepatocellular carcinoma without previous cirrhosis. Previous studies with association of PCT and hepatitis C virus markers, have found liver diseases ranging from cirrhosis to hepatocellular carcinoma. The importance of this study is the absence of cirrhosis.

Cloning and characterization of a cDNA encoding a protein synthesis initiation factor-2alpha (eIF-2alpha) kinase from Drosophila melanogaster. Homology To yeast GCN2 protein kinase

Phosphorylation of the alpha subunit of the eukaryotic initiation factor 2 (eIF-2alpha) is one of the best-characterized mechanisms for downregulating protein synthesis in mammalian cells in response to various stress conditions. In Drosophila, such a regulatory mechanism has not been elucidated. We report the molecular cloning and characterization of DGCN2, a Drosophila eIF-2alpha kinase related to yeast GCN2 protein kinase. DGCN2 contains all of the 12 catalytic subdomains characteristic of eukaryotic Ser/Thr protein kinases and the conserved sequence of eIF-2alpha kinases in subdomain V. A large insert of 94 amino acids, which is characteristic of eIF-2alpha kinases, is also present between subdomains IV and V. It is particularly notable that DGCN2 possesses an amino acid sequence related to class II aminoacyl-tRNA synthetases, a unique feature of yeast GCN2 protein kinase. DGCN2 expression is developmentally regulated. During embryogenesis, DGCN2 mRNA is dynamically expressed in several tissues. Interestingly, at later stages this expression becomes restricted to a few cells of the central nervous system. Affinity-purified antibodies, raised against a synthetic peptide based on the predicted DGCN2 sequence, specifically immunoprecipitated an eIF-2alpha kinase activity and recognized an approximately 175 kDa phosphoprotein in Western blots of Drosophila embryo extracts.

Localization, structure and expression of the gene for translation initiation factor eIF-4E from Drosophila melanogaster

Drosophila melanogaster contains a single copy of the gene encoding translation eukaryotic initiation factor eIF-4E, which maps in the 67A2B1 region of chromosome 3L. A genomic clone containing the entire eIF-4E gene was isolated and sequenced. Comparison of this sequence with a cDNA previously obtained in our laboratory and 5'-RACE analysis revealed the existence of three mRNAs that are generated by alternative splicing of a primary transcript. All of them have different 5' untranslated leader regions. Two of the mRNAs encode the same eIF-4E polypeptide, whose sequence has been deduced from the cDNA clone. The third mRNA species contains a new open reading frame, possibly encoding another isoform of eIF-4E, which is very similar in size to the other but has a different N-terminal sequence. Several sequences which may be involved in the regulation of transcription initiation of the eIF-4E gene, except for a consensus TATA box, were found upstream of the putative transcription initiation sites. Expression of the eIF-4E gene is spatially and temporally controlled during embryonic development. It is ubiquitously expressed during embryogenesis but transcripts preferentially accumulate in certain tissues, particularly in the pole cells, at different developmental stages.

The eIF-2alpha kinases and the control of protein synthesis

Protein synthesis is regulated in response to environmental stimuli by covalent modification, primarily phosphorylation, of components of the translational machinery. Phosphorylation of the alpha subunit of eIF-2 is one of the best-characterized mechanisms for down-regulating protein synthesis in higher eukaryotes in response to various stress conditions. Three distinct protein kinases regulate protein synthesis in eukaryotic cells by phosphorylating the alpha subunit of eIF-2 at serine-51. There are two mammalian eIF-2alpha kinases: the double-stranded RNA-dependent kinase (PKR) and heme-regulated inhibitor kinase (HRI), and the yeast GCN2. The regulatory mechanisms and the molecular sizes of these eIF-2alpha kinases are different. The expression of PKR is induced by interferon, and the kinase activity is stimulated by low concentrations of double-stranded RNA. HRI is activated under heme-deficient conditions. Yeast GCN2 is activated by amino acid starvation. The phosphorylation of eIF-2alpha results in the shutdown of protein synthesis. Nevertheless, the eIF-2alpha kinases can regulate both global as well as specific mRNA translation. Inhibition of protein synthesis correlates with eIF-2alpha phosphorylation in response to a wide variety of different stimuli, including heat shock, serum deprivation, glucose starvation, amino acid starvation, exposure to heavy metal ions, and viral infection. Finally, recent studies suggest a role for eIF-2alpha phosphorylation in the control of cell growth and differentiation.

[Shunt surgery versus disconnection in portal hypertension. A comparative study]

Controversy remains about the best treatment for patients with esophagogastric variceal bleeding. In spite of different therapeutic alternatives and recent progress, such as liver transplantation of TIPS, many patients will finally be treated by standard surgery. With the aim to know the results of surgery in shunting vs non-shunting procedures, we have analyzed a recent and consecutive series of 68 cirrhotics patients operated on for variceal hemorrhage. According to the surgical technique there were three groups: I) 30 patients underwent a total portacaval shunt; II) 18 cases with an azygosportal disconnection; III) 20 patients with a partial portacaval shunt (8-10 mm H-portacaval PTFE graft). All groups were homogeneous considering age, sex etiology, Child-Pugh grade and timing of surgery (elective vs urgent). The complications and mortality rates were similar for the three groups. The overall operative mortality was 10%, and 5% in selected cases (Child-Pugh A-B, non urgent cases). With a follow-up for I, II and III group of 47, 44 and 27 months respectively, chronic encephalopathy have been seen in 61%, 15% and 15% respectively (p < .05). No patient in group I has rebled, and only one case in the II and III groups had a recurrence of hemorrhage. The actuarial three years survival was 76%, 86% and 85% (p NS), and the five year survival was 41% vs 86% for the groups I and II respectively (p < .05). In conclusion, in selected cases, surgery gives excellent immediate and long term results. In patients with variceal bleeding and failure of first line treatments, such as sclerosis or pharmacology, the partial H-portacaval shunt and non-shunting procedures are good alternatives, with low incidence of rebleeding and chronic encephalopathy.

Long esophagoplasty: functional study

The functional results of different types of plasty were evaluated in 46 patients who had undergone esophageal replacement for different pathologies. The patients were classified into three groups according to the type of plasty: I) 19 ileocecocolonoplasties (ICC), II) 11 left colonoplasties (LC), III) 16 gastroplasties (GP). The postoperative studies made were: a) clinical evaluation, b) radiological barium contrast study, c) isotopic transit of semisolid food marked with 99m-Tc colloidal sulfur and d) manometry. The clinical evaluation disclosed no significant differences between the three groups. Isotopic scans revealed more rapid emptying of the ICC, with elimination by the ileal segment in the first minute of 76.3 +/- 3.3% of the isotope, and by the entire plasty of 79.4 +/- 4.2% in 15 minutes (p less than 0.001). The manometric study showed non-response by the GP. The motor activity of the terminal ileoplasty was greater than that of the other plasties studied, and that of the right colonoplasty was greater than that of the left (p less than 0.01). Likewise, the clearance of acid (HCl 0.1N) by the ICC was more rapid than that of the LC (p less than 0.01). It is concluded that, functionally, the ICC is a better long esophagoplasty than the other procedures studied.

Somatostatin in the treatment of severe upper gastrointestinal bleeding: a multicentre controlled trial

To evaluate the effectiveness of somatostatin versus combined cimetidine and pirenzepine in the treatment of upper gastrointestinal (GI) bleeding of peptic origin, a multicentre controlled, prospective, randomized and double blind trial has been undertaken in 60 subjects. Strict selection criteria were followed. All subjects were diagnosed by endoscopy during the first 18 h after admission. Endoscopic stigmata of recent haemorrhage were also evaluated. Sixty-five per cent of the subjects presented with severe upper GI bleeding (blood pressure less than or equal to 100 mmHg, pulse rate greater than or equal to 110, haematocrit less than or equal to 30 per cent), and in 71.6 per cent stigmata were found. Thirty patients (Group 1) received a somatostatin infusion (250 micrograms/h continuously during 120 h) and 30 patients (Group 2) received cimetidine (200 mg IV every 4 h for 5 days) and pirenzepine (10 mg IV every 8 h for 5 days). Both groups were homogeneous for sex, age, backgrounds, bleeding source, grade of bleeding (moderate or severe) and presence or not of stigmata. Bleeding stopped in 27 subjects of Group 1 (90 per cent and in 20 subjects of Group 2 (66.67 per cent) (P less than 0.05, chi 2 test). The time until the bleeding stopped was significantly shorter in patients of group 1 (3.44 +/- 0.53 h) than in patients of group 2 (8.12 +/- 1.94 h) (P less than 0.05, Mann-Whitney U test). The number of blood units required for Group 1 (2.26 +/- 0.35) was significantly lower than the one required for Group 2 (3.90 +/- 0.51) (P less than 0.005, Wilcoxon test). Significant differences were not observed between the two groups regarding cross-over subjects, re-bleeding, surgery (P = 0.0635, Fisher's exact test) and hospital stay. The mortality of the trial was 5 per cent. There was no toxicity during somatostatin, cimetidine or pirenzepine infusion. In conclusion, somatostatin was more effective than cimetidine plus pirenzepine in the control of severe upper GI bleeding of peptic origin, with a lower interval time to stop bleeding and reduced transfusion requirements.

Intramitochondrial lamellar bodies in acute myeloblastic leukemia

Intramitochondrial lamellar bodies were observed in three cases of acute myeloblastic leukemia. Two of the patients had M1 leukemia and the remaining patient M4 leukemia, by the FAB classification. In all three cases neoplastic cells contained dilated mitochondria that varied in size and shape and contained decreased numbers of cristae. Some mitochondria contained lamellar structures that resembled myelin figures and, occasionally, primary granules; these structures were more conspicuous in the central portion of the mitochondria. Regardless of the proliferating cell type (lymphoblasts, myeloblasts, or monoblasts), there are common ultrastructural changes that represent abnormal metabolic function, such as disorders of intramitochondrial protein synthesis. The exact meaning of these findings is not known; adequate interpretation will require further investigation of the biology of these neoplastic processes.