Prospective analysis between the therapy of immunosuppressive medication and allogeneic microchimerism after liver transplantation

After liver transplantation, migration of donor-derived hematopoietic cells to recipient can be detected in peripheral blood. This state is termed microchimerism. The aim of this study was to investigate prospectively the presence of allogeneic microchimerism, the occurrence of acute cellular rejection and the level of immunosuppression in transplanted patients. Microchimerism occurrence between 10 days and 12 months after liver transplantation was analyzed in 47 patients aged between 15 and 65 by a two-stage nested PCR/SSP technique to detect donor MHC HLA-DR gene specifically. A pre-transplant blood sample was collected from each patient to serve as individual negative control. Microchimerism was demonstrated in 32 (68%) of the 47 patients; of these, only 10 patients (31.2%) presented rejection. Early microchimerism was observed in 25 patients (78.12%) and late microchimerism in 7 patients (21.8%). Among the patients with microchimerism, 14 were given CyA and 18 were given FK506. In the group without microchimerism, 12 patients were given CyA and 03 were given FK506. There was a significant association between the presence of microchimerism and the absence of rejection (p=0.02) and also between microchimerism and the type of immunosuppression used. Our data indicate that microchimerism and probably differentiation of donor-derived leukocytes can have relevant immunologic effects both in terms of sensitization of recipient and in terms of immunomodulation toward tolerance induction.

Expanded Milan criteria on pathological examination after liver transplantation: analysis of preoperative data

BACKGROUND

We sought to evaluate the accuracy of imaging techniques related to the Milan criteria (MC) compared with the explant histology and the survival of these patients.

METHODS

Between 1997 and 2006, we selected 45 cirrhotic patients with hepatocellular carcinoma distributed into two groups according to explant histology: MC and Expanded Milan Criteria (EMC). Age, gender, preoperative imaging (ultrasound [US] and/or computed tomography [CT]), maximal tumor dimension, number of tumors, explanted histology, histology degree, alpha-fetoprotein (AFP) level and vascular invasion were compared among the patients to evaluate the value of these prognostic factors for survival after liver transplantation.

RESULTS

By histology 42.2% explants were identified as EMC. The mean AFP level was 204.5 ng/mL. Vascular invasion was detected in 31.5% of explants and 68.4% showed incidental tumors. The survival rates after 10 years were 47.4% whereas MC patients showed 57.77%. The mean AFP level among MC patients was 150.2 ng/mL with vascular invasion detected in 7.7% of explants, and 47.4% with incidental tumors. The overall sensitivity of the imaging techniques was 83.3% for CT and 75% for US. The specificity was 96% for CT and 80.1% for US.

CONCLUSION

Scan examinations in the preoperative evaluation underestimated about 42.2% of tumors. Those patients had vascular invasion but the survival after 10 years was similar between the ECM and MC groups.

Intraoperative massive transfusion decreases survival after liver transplantation

Patients undergoing liver transplantation often experience coagulopathy and massive intraoperative blood loss that can lead to morbidity and reduced survival. The aim of this study was to verify the survival rate and discover predictive factors for death among liver transplant patients who received massive intraoperative blood transfusions. This cohort study was based on prospective data collected retrospectively from January 2004 to July 2006. The 232 patients were distributed according to their blood requirements, (namely, more or less than 6 units), including red blood cell saver. The statistical analyses were performed using Student t test, Cox hazard regression, and the Kaplan-Meier method (log-rank test). The massively transfused cohort displayed higher Child-Pugh classifications (10.2 vs 9.6; P = .03); model for end-stage liver disease (MELD) scores (19 vs 17; P = .02); recipient weights (75.4 vs 71 kg; P = .03); as well as warm ischemia times (70.7 vs 56.4 minutes; P < .001) and surgery times (584.6 vs 503.4 minutes; P < .05). The proportional hazard (Cox) regression analysis showed that the risk of death increased 2.1% for each unit of donor sodium and 1.6% for each additional year of donors age over 50. The survival rates at 6, 12, 60, and 120 months for > or = 6 vs <6 U of blood transfusion of 63.8% vs 83.3%; 53.9% vs 76.3%; 40% vs 60%; 34.5% vs 49.2%. In conclusion, we observed that patients receiving over 6 red blood cell units intraoperatively displayed reduced survival. Predictive factors for this risk factor were high donor level of sodium and of age.

De novo posttransplantation nonlymphoproliferative malignancies in liver transplant recipients

The risk of developing de novo malignancies after liver transplantation is around 1% per year. The incidence varies from 3% to 15%; it is greater than that in the general population. The potential causes for cancer after solid organ grafting are: chronic immunosuppression and human herpes viral infection. The objective of this paper was to review the medical literature about the subject to verify the incidence of de novo malignancies in our service. We performed retrospective analysis of the medical files of 325 successive patients undergoing orthotopic liver transplantation from September 1991 to December 2006. We analyzed the type of tumor, the risk factors, the treatment modality, and the patient survivals. Recurrences of hepatocellular carcinoma were excluded. There were 5 (1.54%) men of average age 50.2 years, and an 80% mortality rate. Their survival time was affected by the nature of the tumor and by the late manifestations of intestinal obstruction allowing adequate surgical treatment. Four of the patients displayed heavy alcohol and tobacco consumption before transplantation. Screening for premalignant lesions must be strongly encouraged to achieve better postoperative results.

Detection and monitoring of human herpesvirus 7 in adult liver transplant patients: impact on clinical course and association with cytomegalovirus

We herein have described HCMV and HHV-7 detection during the follow-up of 29 adult liver recipients in our transplant unit. For basic immunosuppression, the patients received cyclosporine and symptomatic HCMV infection was treated with gancyclovir. The most prevalent etiology for liver transplantation was hepatitis C or alcohol abuse (45% of patients). The laboratory monitoring to 180 days after transplantation was performed by nested-polymerase chain reaction to HCMV or HHV-7. HCMV DNA was detected in 19/29 of patients (65.5%) and HHV-7 DNA, in 14/29 of patients (48.2%). The time-related appearance of HHV-7 and HCMV DNA differed significantly (P = .02); their detection was considered independent (P = .2). The results showed that few patients remained free of HHV-7 or HCMV after liver transplantation, indicating that most patients were actively infected with more then one virus sequentially and not concurrently. Graft dysfunction, fever, gastrointestinal system abnormalities, and interstitial pneumonitis dominated the clinical pictures. Thirteen of 29 patients (44.8%) developed symptomatic HCMV active infections. The relationship between the detection of HCMV DNA, and HCMV disease development was significant (P = .0004). In HCMV-free patients, no symptoms or significant laboratory findings were linked with HHV-7. However, HHV-7 was frequently detected sequentially after HCMV, and an interaction of HCMV and/or HHV-6 to increase their pathogenic effects could not be excluded. Further studies should be performed including HHV-6 to evaluate the relationship, among beta herpesviruses.

Molecular Mechanisms Associated With Donor-Specific Microchimerism in Peripheral Blood of Brazilian Patients After Liver Transplantation

A large number of studies in liver transplantation have demonstrated allogeneic microchimerism. The clinical and immunologic implications of this finding remain inconclusive, just as the influence of HLA mismatch and donor alloreactivity also are controversial. The present study analyzed the presence of allogeneic microchimerism in liver transplant recipients in relation to donor leukocyte kinetics and rejection episodes. The study was extended to determining the influence of immunogenetic factors in patients after liver transplantation. The presence of allogeneic microchimerism was analyzed on peripheral blood of 50 recipients. DNA extracted from the samples was subjected to typing for HLA-DRB1 and -DQB1 alleles by polymerase chain reactions using sequence-specific primers (PCR/SSP). Microchimerism was identified by nested PCR/SSP. Microchimerism was detected in 72% of patients. There was significant effect of microchimerism on rejection episodes (P=.002), while HLA mismatches did not show significance for one or two mismatches (P=.98). Allogeneic microchimerism detected in the majority of liver transplant patients was observed to be significantly associated with rejection episodes.

Retrospective analysis of patients who developed pulmonary hypertension during the early postoperative period after liver transplantation

INTRODUCTION

Pulmonary hypertension (PH) (mean pulmonary arterial pressure [mPAP] > 25 mm Hg) is frequently observed during the postoperative period after liver transplantation (LT).

OBJECTIVE

The objective was to compare respiratory function, intensive care unit (ICU) length of stay (LOS), and 30-day survival rates among patients evolving with PH with those who do versus do not develop it during the postoperative period after LT.

METHODS

Fifty-seven patients undergoing LT from January 1999 to December 2000 were divided into 2 groups: Group 1 (G1; n = 26), without PH; and Group 2 (G2; n = 31), with moderate PH. Preoperative parameters were Child-Pugh's classification, pulmonary function tests, mPAP, and P(A-a)O(2). During the intraoperative period, warm and cold ischemic times and the amount of blood transfusion were evaluated, whereas mPAP, PaO(2)/FiO(2) ratio, weaning time, ICU LOS, and 30-day survival rates were evaluated postoperatively.

RESULTS

mPAP in early postoperative period was 21 +/- 13 mm Hg and 32 +/- 4 mm Hg in G1 and G2, respectively (P <.0001). PaO(2)/FiO(2) was 310 +/- 82 mm Hg in G1 and 272 +/- 84 mm Hg in G2 (P =.48). In G1 and G2, 77% and 74% of patients, respectively, were successfully weaned in the first 24 hours postoperative (P =.10). ICU LOS was 111 hours (range, 45-1098 hours) in G1 and 102 hours (range, 59-284 hours) in G2 (P =.36). The 30-day survival rate was 20 of 26 (77%) in G1 and 26 of 31 (84%) in G2 (P =.44).

CONCLUSION

Our data suggest that moderate PH during the early postoperative phases of LT cannot be considered an additional risk factor for pulmonary dysfunction, and for an increased ICU LOS or 30-day mortality rate.

Liver transplant recipients mortality on the waiting list: long-term comparison to Child-Pugh classification and MELD

We sought to evaluate our experience concerning the high waiting list mortality rate for orthotopic liver transplantation (OLT) using the MELD (Model for End-Stage Liver Disease), which has been shown to predict short-term survival better than Child-Turcotte-Pugh (CTP) classification. The predominant end-stage disease was cirrhosis due to hepatitis C virus (67%), patient mean age was 36.8 years, and 72.1% were men. When the patients were included on a waiting list, the MELD score was stratified into W: 0 to 10; X: 11 to 20, and Y: 21 to 40 and the CPT as A: 5 to 6, B: 7 to 9, and C: 10 to 15. It was also observed that 77.8% of patients were on the waiting list, 16.4% underwent OLT and 5.8% had been removed. The estimated survival rate after 1 year was W = 85.4%; X = 83.3%, Y = 46.8%; A = 81.3%, B = 84.2%, C = 45.9%. Child median score was 8 +/- 1.5 (5 to 15) and the MELD was 14.7 +/- 5.1 (8 to 43). The mortality rate was 20.2%. Severe patients classified as Y or C showed greater mortality than the other groups (P <.001), but no significant difference between Y and C strata. The mortality rate was the same as in previous years.

Role of Choledochojejunostomy in Liver Transplantation

AIM

This study analyzes the efficacy and rate of complications related to Roux-en-Y choledochojejunostomy need either as the primary biliary reconstruction during orthotopic liver transplantation (OLT) or to treat biliary complications.

METHODS

One hundred seventy-seven transplantation procedures were performed from September 1991 to December 2003 in recipients of mean age 51.9 years. Patients were reviewed for the type of biliary reconstruction, the prevalence of biliary complications, and the choice of treatment for these complications. Duct-to-duct anastomosis (group CDC) was performed in 153 patients (85.6%), and choledochojejunostomy (group CDJ) in 24 patients (14.4%). Biliary complications, including stenosis, bile leakage, calculosis, and extensive biliary necrosis, required hospitalization, surgical interventions or endoscopic approaches. Biliary complications in the CDC group first were addressed by endoscopic treatments. When endoscopic therapy failed, they were approached by surgical reintervention. All biliary complications in group CDJ were surgically treated, namely, revision of the Roux-en-Y choledochojejunostomy. The chi square test was used to compare frequencies, with Yates correction when necessary; P values were considered significant at <.05. The Mann-Whitney U test was used to evaluate survival.

RESULTS

Fifty-eight (32.8%) biliary complications in 47 patients required endoscopic or surgical approaches. In group CDJ, 1 patient had bile leakage requiring surgical treatment. The prevalence of biliary complications was lower in the CDJ group than the CDC group (P < .05). Endoscopic treatment applied in 23 patients, failed in 11. Surgical approaches were performed in 11 patients after endoscopic failure, and in 13 patients as the first option to treat biliary complications. No failure was observed with surgical treatment. Cholangitis occurred in 3 patients who received surgical treatment and 4 patients who received endoscopic treatment. There was no statistically significant difference when comparing the mortality rates of the 3 types of treatment for biliary complications: endoscopy, surgery, and endoscopy followed by surgery. Survival rates were similar for the 3 types of treatment of biliary complications.

CONCLUSION

Roux-en-Y choledochojejunostomy is a useful tool to treat biliary complications after OLT, especially when endoscopic treatment fails. In our experience, the rate of complications directly related to this technique is significantly lower than common duct anestomosis, whether used for biliary reconstruction during OLT or for posttransplantation biliary complications.

Gastrointestinal bleeding during liver transplantation--report of two cases

A few authors have reported, especially as intraoperative complications, gastrointestinal hemorrhage related to liver transplantation. The aim of this study was to show two cases of gastrointestinal hemorrhage, which occurred during surgery. The first patient was male, 46 years old, with viral hepatic cirrhosis. He had previously presented two episodes of digestive bleeding. Upper digestive endoscopy showed esophageal gastric varices. During the hepatectomy there was bleeding inside the nasogastric tube associated with severe hemodynamics instability without other sources of bleeding. Intraoperative endoscopy evidenced bleeding gastric varices. Gastrectomy was carried out and the varices were tied. The piggyback technique was used in the liver transplantation. The surgery was concluded without problems and in the following four and a half years his condition has evolved well. In the second case, the patient was aged 17, female, with autoimmune hepatic cirrhosis. She had previously presented one episode of digestive bleeding. Intraoperative endoscopy showed median esophageal varices. During the anesthetic induction she presented an episode of hematemesis. A Sengstaken-Blakemore balloon was introduced. The transplant was performed without further problems. Her case has been followed for 14 months in the outpatients' clinic with a good postoperative course. To sum up, gastrointestinal hemorrhage can be due to portal hypertension during the liver transplantation and must be treated quickly. In these cases the surgery must be ongoing.

Development of donor-specific microchimerism in liver transplant recipient with HLA-DRB1 and -DQB1 mismatch related to rejection episodes

Migration of donor-derived cells to recipient tissues after liver transplantation has been suggested as a mechanism to induce and maintain allograft tolerance, although important issues remain including acute rejection posttransplantation mortality, and complications related to immunosuppressive therapy. We therefore examined the relation of rejection to chimerism based upon recipient and donor mismatch of HLA-DRB1 and -DQB1 alleles. Laboratory analysis of peripheral blood was performed before and 10 days to 16 months after liver transplantation in 32 recipients, using ganglion or spleen cell samples of respective donors. DNA was extracted for HLA-DRB1 and DQB1 allele typing using polymerase chain reactions with sequence-specific primers (PCR-SSP). Microchimerism was analyzed through nested PCR. Our results confirmed that patients with one or two mismatched HLA-DRB1 and-DQB1 alleles showed microchimerism and no rejection (P <.05). Microchimerism was present in 71.88% of the patients, and a significant association of rejection P <.05 was found when microchimerism was correlated to graft rejection. These results suggest that the presence of microchimerism may be associated with acceptance, tolerance and survival of the allograft.

Can the use of marginal liver donors change recipient survival rate?

Liver transplantation as a therapeutic method for the treatment of end-stage liver disease is beclouded by a scarcity of organs. The aim of this study was to retrospectively analyze the relation between the classification of donors as marginal versus ideal and recipients survival after 148 of 197 orthotopic liver transplantations (OLT) performed from 1991 to 2001. Donors were classified as marginal if they showed the major criteria of: age over 55 years, aspartate aminotransferase greater than 150 UI/L; serum bilirubin greater than 2 mg/dL, serum sodium greater 150 mEq/L, high-dose dopamine or any other vasoactive amine, cardiac arrest, intensive care unit (ICU) stay over 5 days, and moderate severe macrosteatosis. The minor criteria for a marginal donor were: use of dopamine below 10 microg/kg/min, history of alcoholism, drug abuse, ICU stays less than 4 days, microsteatosis of any degree, and mild macrosteatosis. Statistical analysis was performed using Cox regression analyzing and the Kaplan-Meier survival method. The rate of marginal donors was 61.5%. The 180 postoperative day survival was 77.0%. Survival rates were 81.1% for recipients of marginal donor organs, and 70.7% for ideal donor recipients (P >.05). In conclusion, the use of marginal liver donors is viable and safely expands the numbers of liver transplants, thereby diminishing the number of waiting list deaths.

Late hepatic artery thrombosis after liver transplantation: clinical setting and risk factors

The aim of this study was to assess the prevalence clinical presentation, and impact on outcome of late hepatic artery thrombosis (HAT) after OLT. We also sought risk factors other than technical problems that predispose to the pathogenesis of late HAT among 178 OLT performed from 1999 to 2002. Late HAT was diagnosed using Doppler ultrasonography and arteriography. Late HAT was observed in nine patients (3.8%), all of whom had experienced chronic HCV infection. Median time to HAT diagnosis was 4.88 months after OLT. Mean follow-up time was 40.25 months. Recipient age ranged from 30 to 61 years and median donor age, 28 years. Mean warm ischemia time was 63 minutes and mean cold ischemia time, 660 minutes. All of our study group were cigarette smokers. Postoperative CMV infection, presenting with hepatitis, had been treated in 55.6%. Before the diagnosis of HAT more than one episode of acute cellular rejection had been observed in six patients (55.6%) and 44.5% had chronic rejection. The diagnosis of CR was established after the diagnosis of HAT in all cases. Recurrence of HCV infection was histologically documented in 44.5%. Only one patient experienced graft loss (77 months after OLT). Six of nine patients had biliary complications, treated either by endoscopic stenting or by surgical drainage. Two patients were asymptomatic. In conclusion, late HAT shows a benign presentation that has no impact on graft survival. Possible risk factors have yet to be defined by multicenter trials.

[Conservative treatment of benign esophageal strictures using dilation. Analysis of 500 cases]

The benign esophageal stenoses (BES) are common complications owing to many etiologies: gastroesophageal reflux, ingestion of corrosive agents, esophageal surgery, radiotherapy, postendoscopic variceal sclerotherapy, drug ingestion, prolonged nasogastric intubation, extrinsic compression and esophageal webs. Esophageal dilatations are worldwide recommended to treat this complication, employing dilators of many types and diameters and facilitating the food ingestion.

PURPOSE

Evaluation of the results and advantages of the conservative treatment of the BES using esophageal dilatations, in outpatient service of upper digestive endoscopy.

METHODS

During the period from 1981 to 1999, 500 patients with BES were treated and followed up at the Gastrocenter - UNICAMP, in an individually Program of Esophageal Dilatation for each case. The highest number of cases was under ages from 31 to 60 years old (52,8%), and males (59,2%). The most predominant etiologies were: peptic stenosis (30,4%), caustic ingestion (23,6%), anastomosis (23,2%), megaesophagus (8,0%) and prolonged nasogastric ingestion entubation (6,4%), totalizing 91,6% of the BES. Most of patients (94,2%) were submitted to the maximum of 25 dilations. Dilators from 10,5 to 16 mm were employed in 95,6% of the cases. The duration of the treatment was 24 months in 76,2% of the BES. Esophageal perforations occurred in 6 patients (1,2%), without mortality.

RESULTS

Were considered excellent, good and bad results, respectively in 76,2%, 18,2% and 5,6% of the cases. On the other hand, excellent results were recorded in 81,0% of the peptic stenosis, 66,1% of the caustic stenosis and 82,7% of the anastomotic stenosis. The conservative treatment failed in 9,3% of the caustic stenosis, 4,3% of the anastomotic stenosis and 3,9% of the peptic stenosis. Thus, the caustic stenosis were unsuccessfull in the highest percentage of unsuccessful.

CONCLUSION

The conservative treatment using guidewire dilators (Savary-Gilliard and Eder-Puestow) is the first choice in the BES, is effective for long time, with short complications and the surgical treatment is indicated only when the dilatations failed.

[Study of renal glucose release in rabbits submitted to total functional hepatectomy and norepinephrine infusion]

AIM

To study the possible endogenous sources of glucose in the absence of the liver (equivalent to the anhepatic period of liver transplantation).

MATERIAL AND METHODS

A experimental model of total functional hepatectomy in anesthetized rabbits was developed. The aorta and the right renal vein were catheterised in order to collect blood samples to measure glucose contents. The animals were divided into two groups: group 1, 5 animals underwent only norepinephrine infusion; group 2, 15 animals underwent norepinephrine infusion and submitted to total functional hepatectomy.

RESULTS

In group 2, before the hepatectomy, arterial glucose levels were higher than venous ones and after the liver removal, the venous levels became higher than the arterial ones. This pattern showed an inversion in the glycemic curves. In group 1 this pattern was not observed.

CONCLUSION

The glycemic curves behavior observed in group 2 its not due to norepinephrine infusion, but represents renal glucose release after total functional hepatectomy.

[Videolaparoscopic surgical treatment of gastroesophageal reflux disease: modified Nissen technique - clinical and functional results]

BACKGROUND

Gastroesophageal reflux disease is highly common worldwide and surgical treatment is being indicated more frequently. Currently, laparoscopic is the access of choice and several antireflux techniques may be used. We prefer a modified Nissen technique.

PURPOSE

To analyze preoperative clinical and functional parameters and compare with postoperative outcome of a modified valve technique performed by laparoscopy.

METHODS

A group of 59 patients underwent laparoscopic modified Nissen valve. Preoperative diagnosis was made by radiological contrast exams and endoscopy in all patients. Esophagus manometry was performed in 35 patients and scintigraphy scan in 15 patients. Complicated esophagitis occurred in 54.2%, with 21 (35.6%) patients presenting a Barrett's epithelium. Laparoscopic surgery was performed in all patients with no conversion to open surgery, with an average time of 123.9 minutes.

RESULTS

There were no intraoperative complications. Hospital discharge occurred in an average of 47.6 hours. Symptoms as dysphagia, pain, regurgitation and flatus occurred in 48.1% of the patients in the first thirty days. Average follow-up was 20.8 months. Postoperative radiological, endoscopic, manometric and scintigrafic scan exams showed a significant improvement, as well as clinical assessment using Visick's classification, which showed excellent and good results in 93.1% of the patients.

CONCLUSION

Comparative analysis of clinical assessment and exam results lad us to conclude that modified Nissen surgery by laparoscopic access corrects gastroesophageal reflux in most patients followed-up.

Chemical pleurodesis for hepatic hydrothorax

BACKGROUND

Ascites can occur after hepatic diseases causing dyspnea, coughing and pain. When associated with pleural effusion it can also increase respiratory distress. In a bibliographic survey hydrothorax has been observed in up to 20% of the patients and the kind of treatment is still being discussed.

OBJECTIVE

This case report shows the occurrence of a large volume of ascites and pleural effusion in a cirrhotic patient and his treatment.

METHODS

Report the case of a patient with hepatic cirrhosis due to chronic alcoholism and massive pleural effusion and ascites. He was submitted to several pleural paracenteses without success. Scintigraphy showed the presence of ascites and confirmed a possible pleuroperitoneal communication. The thoracic surgery group was called and after evaluation it was decided to submit the patient to a pulmonary decortication and chemical pleurodesis.

RESULTS

These procedures were carried out with success. The pleural effusion was solved and the treatment of ascites was decided upon because the patient did not accept any surgical procedure.

CONCLUSION

This treatment could be applied to patients with hydrothorax who could not be submitted to a liver transplantation.

[Laparoscopy in the diagnosis of intra-abdominal diseases. Analysis of 168 cases]

The laparoscopy has been more and more frequently indicated in the last years, for the complementary diagnosis of intraabdominal diseases and abdominal repercussion of systemic diseases. Modern equipaments including videolaparoscopy and the use of either forceps or biopsy needle permit higher safety and significant diagnostic capacity.

PURPOSE

To perform laparoscopy for the diagnosis of intraabdominal and sistemic diseases.

METHODS

During the last 9 years 168 patients were submitted to laparoscopy and the main indications were: ascites--43 cases (25.5%); liver diseases--42 cases (25%); gastric cancer--37 cases (22%); lymphoma--17 cases (10.1%); abdominal tumour--9 cases (5.4%); peritoneal tuberculosis--8 cases (4.8%); liver tumour--6 cases (3.6%); mesenteric cyst--1 case (0.6%) and other diseases--5 cases (3.0%). Ninety nine patients were male (58.9%) aging from 9 to 78 years old (median 47.6 years). Liver biopsies were performed in 92 cases (54.7%) and other tumour biopsies in 26 cases (15.4%).

RESULTS

The diagnosis of the diseases were established or confirmed by laparoscopy in 145 patients (86.3%). In 25 cases of gastric cancer (67.5%) laparoscopy contraindicated the laparotomy, owing to advanced disease. Two patients presented bleeding (1.2%) after liver biopsies and laparotomy was immediately indicated. One of them, whose diagnosis was systemic lupus, presented abdominal abscess, bronchopneumony and died (0.6%).

CONCLUSION

Laparoscopy has small number of complications, and when employed as a diagnostic complementary method therapeutic procedures, avoids laparotomies and accelerate therapeutic procedures.

[Indication and results of liver transplantation in adults]

Increase of survival of patients submitted to transplantation is much superior when compared to other treatments in patients suffering terminal chronic hepatic failure. This fact has been allowing earlier indication of hepatic transplantation in lower operative risk patients. Pre-operative cardiocirculatory evaluation is essential, because during surgery hemodynamic and cardiac output alterations shall occur. The actual survival above 75% suggests that it is easier nowadays to look for factors responsible for mortality than to those predictable by survival. Postoperative survival analysis shows better results in cholestatic diseases (primary biliary cirrhosis and sclerosing cholangitis). Regarding hepatocelular carcinoma over cirrhotic liver, the best results are detected in small lesions up to 3 cm.

[Incidence and epidemiology of Barrett's epithelium at the Gastrocentro-UNICAMP]

It is very important in the clinical practice to identify the individuals with Barrett's esophagus, because they are at risk to develop adenocarcinoma in the columnar epithelium. The objective of this research is to verify the incidence of this specific kind of epithelium at the "Gastrocentro", at State University of Campinas-UNICAMP, Campinas, SP, Brazil, among the total of 15,976 upper digestive endoscopies, performed from january of 1992 to December of 1995. From the total examinations performed were identified 2,381 patients (14.9%) presenting reflux esophagitis (grades I-IV, Savary-Miller). Among this group of patients, the endoscopist suspected of Barrett's esophagus in 110 cases (4.6%) and biopsed the distal esophagus. However, only in 85 cases (77.3%) the pathologist confirmed the diagnosis of Barrett's epithelium. The patients with Barrett's esophagus were 53 males (62.3%), presenting the mean age of 52.2 years and the following grades of esophagitis: grade I-33 cases (38.8%); grade II-15 cases (17.7%); grade III-15 cases (17.7%), grade IV-12 cases (14.1%) and without esophagitis-10 cases (11.7%). The incidence of Barrett's esophagus among the patients with reflux esophagitis was 3.57%, and among the total of examinations performed at the "Gastrocentro" during the period of four years was 0.53%, totalizing 22,4 cases/100,000 habitants.

Effect of fundoplication on the gastric emptying of liquids

To evaluate the effect of fundoplication on the gastric emptying (GE) of liquids, the authors studied 96 male Wistar rats divided into three main groups: group E (early postoperative), formed by 32 rats that received physiological saline as a test meal and whose gastric emptying was evaluated 8 days after surgery; group L (late postoperative), which received the same test meal but was evaluated 29 days after surgery; and group G (glucose), which received 5% glucose in water and was studied 8 days after surgery. Each group was subdivided in two subgroups of 16 animals: in one (atropine), the animals received intravenous (I.V.) atropine sulfate (0.3 mg/100 mg rat weight) 60 minutes before GE test; the other subgroup (controls) received I.V. physiological saline. In both subgroups 8 animals had been submitted to fundoplication and 8 to sham operation. Every test meal, containing 6 mg% red phenol, was infused by gravity through a metallic catheter. Gastric retention was determined by measuring the concentration of the marker in the liquid recovered from the stomach 10 minutes after infusion. In the animals of group E, fundoplication increased the gastric emptying of physiological saline, both in the control and the atropine subgroups. In the L group, gastric retention values were similar in fundoplication and sham-operated rats, suggesting an adaptation of the stomach to the fundoplication. In the G group, fundoplication enhanced GE among the control animals, but not among those receiving I.V. atropine sulfate. These results support the importance of gastric emptying studies in every patient to be submitted to fundoplication.

[The gastroduodenal mucosa in patients with portal hypertension: correlation with blood gastrin]

PURPOSE

gastroduodenal mucosa of two groups of patients with chronic liver disease was studied: schistosomotic mansoni patients (SH) and non-schistosomic patients (NSH). Results were compared to serum-gastrin levels. TYPE: prospective study.

PLACE

Unicamp University Hospital (Hospital das Clínicas), Campinas, São Paulo, Brazil.

PATIENTS

24 patients were included in the results, out of 26 patients studied. Two groups of study: 12 patients with schistosomiasis and liver fibrosis (SH), and 12 patients with liver cirrhosis (NSH) secondary to alcoholism or to hepatitis.

PROCEDURES

esophagogastroduodenoscopies and biopsies of gastric antrum and duodenum. Function tests of the liver were also studied.

RESULTS

results of gastrinemia were found within normal ranges in both groups. Student test ("t") did not show differences between groups at the 5% level. However, patients with chronic liver cirrhosis had more significant and severe endoscopic findings and chronic inflammatory processes of the gastroduodenal mucosa (acute gastritis, duodenitis and ulcers) than patients with liver fibrosis.

CONCLUSIONS

patients with liver cirrhosis due to high risk of gastroduodenal bleeding should be maintained under continuous vigilance, appropriate diet and mucosa cytoprotectors. Furthermore, more research is required to study the etiology of gastroduodenal lesions in these specific groups of patients.