Public Opinions on Removing Disincentives and Introducing Incentives for Organ Donation: Proposing a European Research Agenda

The shortage of organs for transplantations is increasing in Europe as well as globally. Many initiatives to the organ shortage, such as opt-out systems for deceased donation and expanding living donation, have been insufficient to meet the rising demand for organs. In recurrent discussions on how to reduce organ shortage, financial incentives and removal of disincentives, have been proposed to stimulate living organ donation and increase the pool of available donor organs. It is important to understand not only the ethical acceptability of (dis)incentives for organ donation, but also its societal acceptance. In this review, we propose a research agenda to help guide future empirical studies on public preferences in Europe towards the removal of disincentives and introduction of incentives for organ donation. We first present a systematic literature review on public opinions concerning (financial) (dis)incentives for organ donation in European countries. Next, we describe the results of a randomized survey experiment conducted in the United States. This experiment is crucial because it suggests that societal support for incentivizing organ donation depends on the specific features and institutional design of the proposed incentive scheme. We conclude by proposing this experiment's framework as a blueprint for European research on this topic.

No indications for platelet activation in acute clinical myocardial or renal ischemia/reperfusion injury

The pathophysiology of ischemia/reperfusion (I/R) injury is complex and poorly understood. Animal studies imply platelet activation as an initiator of the inflammatory response upon reperfusion. However, it remains unclear whether and how these results translate to clinical I/R. This study evaluates putative platelet activation in the context of two forms of clinical I/R (heart valve surgery with aortic-cross clamping, n = 39 and kidney transplantation, n = 34). The technique of sequential selective arteriovenous (AV) measurements over the reperfused organs was applied to exclude the influence of systemic changes occurring during surgery while simultaneously maximizing sensitivity. Platelet activation and degranulation was evaluated by assessing the expression levels of established markers, i.e. RANTES (Regulated on Activation, Normal T Cell Expressed and Secreted), β-thromboglobulin (β-TG), platelet-derived growth factor (PDGF)-BB and CXCL8 (known as interleukin-8), and by employing an in-vitro assay that specifically tests for platelet excitability. Moreover, a histological analysis was performed by means of CD41 staining. Results show stable RANTES, β-TG, PDGF-BB and CXCL8 AV-concentrations within the first half hour over the reperfused organs, suggesting that myocardial and renal I/R are not associated with platelet activation. Results from the platelet excitability assay were in line with these findings and indicated reduced and stable platelet excitability following renal and myocardial reperfusion, respectively. Histological analysis yield evidence of platelet marginalization in the reperfused organs. In conclusion, results from this study do not support a role for platelet activation in early phases of clinical I/R injury.

Expression of the chemokine receptor CXCR3 and its ligand IP-10 during human cardiac allograft rejection

BACKGROUND

Chemokines play an essential role in regulating the infiltration of leukocytes into allografts in experimental models. Little is known of their expression or function after human cardiac transplantation.

METHODS AND RESULTS

We analyzed 169 sequential human endomyocardial biopsies by immunocytochemistry for infiltration by CD3(+) T cells and the expression of the chemokine receptors CCR1, CCR3, CCR5, and CXCR3. In both cross-sectional and longitudinal analyses, the expression of each of the chemokine receptors correlated with the degree of CD3(+) T-cell infiltration. In particular, the expression of CXCR3 was temporally and spatially associated with CD3(+) T-cell infiltrates and correlated with the histopathological diagnosis of acute rejection (OR, 11.73 and 4.05, respectively; P<0.001). Of 7 patients followed up longitudinally for 1 year, 4 with consecutive biopsies developed intimal thickening by intravascular ultrasound. In these patients, there was a trend for persistent expression of CD3- and CXCR3-expressing infiltrates in the later part of the first posttransplant year. The chemokines eotaxin, IP-10, lymphotactin, MCP-1, Mig, RANTES, and SDF-1 were examined in an additional 35 biopsies by RT-PCR. Eotaxin, lymphotactin, MCP-1, Mig, and SDF-1 were present in both normal and rejecting biopsies. However, the CXCR3 ligand IP-10, which was rarely expressed in normal biopsies, was markedly induced in acute rejection (OR, 19.43; P=0.01).

CONCLUSIONS

The presence of CXCR3(+) T cells and the CXCR3 ligand IP-10 within endomyocardial biopsies is strongly associated with acute rejection. The CXCR3-IP-10 interaction warrants consideration as a therapeutic target in the management of cardiac allograft recipients.

Ligation of CD40 induces the expression of vascular endothelial growth factor by endothelial cells and monocytes and promotes angiogenesis in vivo

This study addresses a mechanism by which lymphocytes may promote vascular endothelial growth factor (VEGF) expression and angiogenesis in immune inflammation. Resting human umbilical endothelial cells (HUVECs) were found to express low levels of VEGF messenger RNA (mRNA) by reverse transcription polymerase chain reaction and ribonuclease protection assay with little or no change in expression following activation by cytokines, including tumor necrosis factor-alpha, interleukin (IL)-1, interferon gamma, or IL-4. In contrast, treatment of HUVECs and monocytes with soluble CD40 ligand (sCD40L) resulted in a marked dose-dependent induction of VEGF mRNA (approximately 4-fold), which peaked between 1 and 5 hours post-stimulation. Transient transfection of HUVECs was performed with a luciferase reporter construct under the control of the human VEGF promoter. Treatment of transfected HUVECs with sCD40L was found to enhance luciferase activity (approximately 4-fold) compared with controls, similar to the relative fold induction in mRNA expression in parallel cultures. Thus, CD40-dependent VEGF expression was a result of transcriptional control mechanisms. Treatment of HUVECs with sCD40L was also found to function in vitro to promote growth and proliferation in a VEGF-dependent manner, and CD40-dependent HUVEC growth was comparable to that found following treatment with recombinant human VEGF. Furthermore, subcutaneous injection of sCD40L in severe combined immunodeficient and nude mice induced VEGF expression and marked angiogenesis in vivo. Taken together, these findings are consistent with a function for CD40L-CD40 interactions in VEGF-induced angiogenesis and define a mechanistic link between the immune response and angiogenesis. (Blood. 2000;96:3801-3808)

The role of the graft endothelium in transplant rejection: evidence that endothelial activation may serve as a clinical marker for the development of chronic rejection

In this review, we discuss the role of the allograft endothelium in the recruitment and activation of leukocytes during acute and chronic rejection. We discuss associations among endothelial activation responses, the expression of adhesion molecules, chemokines and chemokine receptors, and rejection; and we propose that endothelial vascular cellular adhesion molecule-1 (VCAM-1) may be used as a surrogate marker of acute rejection and allograft vasculopathy. In addition, we describe potential mechanistic interpretations of persistent endothelial cell (EC) expression of major histocompatibility complex (MHC) class II molecules in allorecognition. The graft endothelium may provide an antigen-specific signal to transmigrating, previously activated, T cells and may induce B7 expression on locally transmigrating leukocytes to promote costimulation. Taken together, these functions of the EC provide it with a potent regulatory role in rejection and in the maintenance of T-cell activation via the direct and/or the indirect pathways of allorecognition.

Warm flush at 37 degrees C following cold storage attenuates reperfusion injury in preserved rat livers

Pretransplant rinse solutions have been shown to reduce reperfusion injury in cold-stored liver grafts, especially at the nonparenchymal level in sinusoidal endothelial cells (SEC). In this study, different rinse temperatures were tested in a rat liver preservation model. Livers were washed out in situ via the portal vein with cold (4 degrees C) University of Wisconsin (UW) solution, and after hepatectomy (t0), were stored for 8, 16, or 24 h of cold ischemia time (CIT). After storage, livers were flushed with UW solution at either 4 degrees C, 20 degrees C, or 37 degrees C and reperfused for 90 min (37 degrees C). Control livers were reperfused at t0 without preflush. Levels of hyaluronic acid (HA), purine nucleoside phosphorylase (PNP), AST, and LDH were measured in the reperfusion medium. Bile production was monitored during reperfusion. At the end of reperfusion, liver biopsies were taken for enzyme hystochemistry (5'-nucleotidase and LDH). After 8-h CIT and a flush at 4 degrees C, a release of endogenous HA (-7%) was observed, whereas uptake of exogenous HA occurred after the 20 degrees C flush (2%, P = NS) and after the 37 degrees C flush (24%, p < 0.001). HA release occurred at all three preflush temperatures after the 16-h CIT but was significantly lower when flushed at 37 degrees C (-10%) that at 4 degrees C and 20 degrees C (-64% and -17%, respectively, p = 0.05). After the 24-h CIT, the release of endogenous HA increased in the 4 degrees C and 20 degrees C preflush groups, but not in the 37 degrees C group. Levels of PNP and AST increased until the 24-h CIT in all groups but were significantly lower after preflush at 37 degrees C. Release of LDH did not increase with increasing periods of cold storage in any of the flush series. Compared to control livers, mean bile production during reperfusion was significantly decreased following preflush at 4 degrees C or 37 degrees C after all periods of CIT. No differences in mean bile production could be demonstrated in the three preflush groups after any period of CIT. LDH activity in liver tissue was best preserved after the 8 and 16-h CIT in combination with the 37 degrees C preflush, indicating less hepatocellular damage. In conclusion, in cold stored rat livers flushed at 37 degrees C before reperfusion, SEC and hepatocellular damage is attenuated.

No attenuation of ischemic and reperfusion injury in Kupffer cell-depleted, cold-preserved rat livers

Activated Kupffer cells (KC) have been implicated in the damage sustained by preserved liver grafts during ischemia and reperfusion. The aim of this study was to compare ischemia/reperfusion injury in preserved, KC-depleted rat livers and preserved control livers, with special regard to sinusoidal endothelial cell (SEC) injury. Wistar rats were injected with liposome-encapsulated dichloromethylene diphosphonate, 48 hr before hepatectomy, to eliminate KC, or were withheld this pretreatment (controls). Livers were flushed with cold University of Wisconsin solution and after 0, 8, 16, or 24 hr of storage at 4 degrees C, were reperfused in a recirculation system with 200 ml of oxygenated Krebs-Henseleit solution at 37 degrees C for 90 min. Damage to SEC was measured by the uptake of hyaluronic acid (HA) from the perfusate and release of purine nucleoside phosphorylase (PNP). Perfusate samples were, furthermore, analyzed for aspartate aminotransferase (AST) and tumor necrosis factor-alpha. Carbon particles were infused in the perfusate to determine the phagocytotic capacity of KC. Biopsies were taken for histological examination and sections were stained with ED2 monoclonal antibodies to confirm the absence of KC. After 90 min of reperfusion, immediately after cold flush (t0), the uptake of HA was 72.2+/-2.3% and 69.3+/-1.3% in KC-depleted livers and in control livers, respectively (n.s.). After 8 hr of storage, HA uptake was 21.6+/-4.5% and 34.6+/-8.0%, respectively (n.s.). After 16 and 24 hr of storage and reperfusion, no uptake of HA was found in either KC-depleted or control livers, indicating abolished SEC function. PNP activities in the perfusate were higher in control livers (after 8 and 24 hr of storage), presumably due to release from damaged KC. No difference was found in AST and no tumor necrosis factor-alpha was measured in the perfusates of normal and KC-depleted livers. Electron microscopic studies showed that after 8 and 24 hr of storage and reperfusion, KC were activated and were able to phagocytose colloidal carbon. Our conclusion was that the elimination of Kupffer cells did not result in reduction of ischemic and reperfusion damage in livers preserved up to 24 hr, as assessed in vitro by SEC uptake of HA, PNP release, and AST release.

Hyaluronic acid uptake in the assessment of sinusoidal endothelial cell damage after cold storage and normothermic reperfusion of rat livers

The uptake of hyaluronic acid (HA) was used to assess preservation damage to sinusoidal endothelial cells (SEC) during cold storage and subsequent normothermic reperfusion of rat livers. After 8, 16, 24, and 48 h storage in University of Wisconsin (UW) solution, livers were gravity-flushed via the portal vein with a standard volume of cold UW solution containing 50 micrograms/l HA. The effluent was collected for analysis of HA, aspartate aminotransferase (AST), and lactate dehydrogenase (LDH). The mean uptake of HA at 0 h was 59.1% +/- 4.6% (mean +/- SEM). After 8 h of storage, HA uptake was similar (55.5% +/- 7.3%), whereas after 16 h of storage it was reduced to 34.7% +/- 5.8%. At 24 and 48 h of storage, no uptake of HA was found. In a second series of experiments, livers were stored in UW solution and subsequently reperfused for 90 min with a Krebs-Henseleit solution (37 degrees C) in a recirculating system containing 150 micrograms/l HA. Following 8 h of storage, 34.6% +/- 8.0% of the initial HA concentration was taken up from the perfusate. After 16 and 24 h of storage, no uptake of HA was found. The results of this study indicate that damage to SEC occurs progressively during storage, leading to zero uptake of HA by the rat livers at 24 h of cold ischemia time. Additional reperfusion injury to the SEC was demonstrated by the reduced ability of the SEC to take up HA following normothermic reperfusion. The uptake of exogenous HA in preserved livers, used as a tool to assess SEC injury, enables the detection of early preservation damage.

Hyaluronic acid uptake in the assessment of sinusoidal endothelial cell damage after cold storage and normothermic reperfusion of rat livers

The uptake of hyaluronic acid (HA) was used to assess preservation damage to sinusoidal endothelial cells (SEC) during cold storage and subsequent normothermic reperfusion of rat livers. After 8, 16, 24, and 48 h storage in University of Wisconsin (UW) solution, livers were gravity-flushed via the portal vein with a standard volume of cold UW solution containing 50 micrograms/l HA. The effluent was collected for analysis of HA, aspartate aminotransferase (AST), and lactate dehydrogenase (LDH). The mean uptake of HA at 0 h was 59.1% +/- 4.6% (mean +/- SEM). After 8 h of storage, HA uptake was similar (55.5% +/- 7.3%), whereas after 16 h of storage it was reduced to 34.7% +/- 5.8%. At 24 and 48 h of storage, no uptake of HA was found. In a second series of experiments, livers were stored in UW solution and subsequently reperfused for 90 min with a Krebs-Henseleit solution (37 degrees C) in a recirculating system containing 150 micrograms/l HA. Following 8 h of storage, 34.6% +/- 8.0% of the initial HA concentration was taken up from the perfusate. After 16 and 24 h of storage, no uptake of HA was found. The results of this study indicate that damage to SEC occurs progressively during storage, leading to zero uptake of HA by the rat livers at 24 h of cold ischemia time. Additional reperfusion injury to the SEC was demonstrated by the reduced ability of the SEC to take up HA following normothermic reperfusion. The uptake of exogenous HA in preserved livers, used as a tool to assess SEC injury, enables the detection of early preservation damage.

Multiorgan donation in The Netherlands: limited by consent and policy

The percentage of multiorgan donors (MOD) versus single organ donors of kidneys only (SOD-K) has remained markedly low in the Netherlands compared to the other countries in the Eurotransplant region. This suggests a possible loss of donor organs. We investigated the causes of this persisting low percentage of MOD by studying the reasons for kidney donation only. All kidney donors in the Eurotransplant region in 1992 were studied retrospectively. In order to be able to make a comparison between all countries investigated, non heart-beating donors and donors older than 55 years were excluded. Medical reasons were the most frequent cause for kidney donation only in the Netherlands, but this was not significantly different from the other countries in the Eurotransplant region. Multiorgan donation in the Netherlands was restricted by upper age limits for heart and liver transplantation and by the consent system.

Prognostic factors for survival after pancreaticoduodenectomy for patients with carcinoma of the pancreatic head region

BACKGROUND

The aim of this study was to determine prognostic factors for survival after pancreaticoduodenectomy (PD) for carcinoma of the pancreatic head region.

METHODS

From 1983 to 1992. 176 patients underwent PD for ampullary carcinoma (n = 67), distal bile duct carcinoma (n = 42), or pancreatic carcinoma (n = 67). The first choice for resection was subtotal PD (n = 146), but patients with a tumor-positive pancreatic margin or a brittle pancreatic duct underwent total PD (n = 30).

RESULTS

Hospital mortality was 4.7% after subtotal PD and 20% after total PD. Overall 5-year survival was 31%. Survival after PD for ampullary carcinoma care. (5-year, 50%) was significantly better (P < 0.001) than for distal bile duct carcinoma (24%) and pancreatic carcinoma (14%). Independent negative prognostic factors for survival (multivariate analysis) were involved resection margins (hazard rate ratio [HRR] 4.08), major vascular involvement (HRR 2.20), distal bile duct or pancreatic origin of carcinoma (HRR 1.93), and perioperative blood transfusion of more than 4 U (HRR 1.76). Tumor size (> 2 cm), regional lymph node involvement, and a poor differentiation grade were overall negative factors in univariate analysis but not in the subgroup of ampullary carcinoma.

CONCLUSION

Involvement of resection margins, major vascular ingrowth, site of origin of carcinoma, and perioperative blood transfusion were independent prognostic factors for survival after PD. Overall 5-year survival was 31%, and subtotal PD is advocated for all patients with a macroscopically resectable tumor in the pancreatic head region without major vascular involvement, even for those with larger tumors or local lymph node metastasis. Care should be taken to limit the need for perioperative blood transfusions.

Prognostic factors for survival after pancreaticoduodenectomy for patients with carcinoma of the pancreatic head region

BACKGROUND

The aim of this study was to determine prognostic factors for survival after pancreaticoduodenectomy (PD) for carcinoma of the pancreatic head region.

METHODS

From 1983 to 1992. 176 patients underwent PD for ampullary carcinoma (n = 67), distal bile duct carcinoma (n = 42), or pancreatic carcinoma (n = 67). The first choice for resection was subtotal PD (n = 146), but patients with a tumor-positive pancreatic margin or a brittle pancreatic duct underwent total PD (n = 30).

RESULTS

Hospital mortality was 4.7% after subtotal PD and 20% after total PD. Overall 5-year survival was 31%. Survival after PD for ampullary carcinoma care. (5-year, 50%) was significantly better (P < 0.001) than for distal bile duct carcinoma (24%) and pancreatic carcinoma (14%). Independent negative prognostic factors for survival (multivariate analysis) were involved resection margins (hazard rate ratio [HRR] 4.08), major vascular involvement (HRR 2.20), distal bile duct or pancreatic origin of carcinoma (HRR 1.93), and perioperative blood transfusion of more than 4 U (HRR 1.76). Tumor size (> 2 cm), regional lymph node involvement, and a poor differentiation grade were overall negative factors in univariate analysis but not in the subgroup of ampullary carcinoma.

CONCLUSION

Involvement of resection margins, major vascular ingrowth, site of origin of carcinoma, and perioperative blood transfusion were independent prognostic factors for survival after PD. Overall 5-year survival was 31%, and subtotal PD is advocated for all patients with a macroscopically resectable tumor in the pancreatic head region without major vascular involvement, even for those with larger tumors or local lymph node metastasis. Care should be taken to limit the need for perioperative blood transfusions.

Prognostic factors for survival after pancreaticoduodenectomy for patients with carcinoma of the pancreatic head region

BACKGROUND

The aim of this study was to determine prognostic factors for survival after pancreaticoduodenectomy (PD) for carcinoma of the pancreatic head region.

METHODS

From 1983 to 1992. 176 patients underwent PD for ampullary carcinoma (n = 67), distal bile duct carcinoma (n = 42), or pancreatic carcinoma (n = 67). The first choice for resection was subtotal PD (n = 146), but patients with a tumor-positive pancreatic margin or a brittle pancreatic duct underwent total PD (n = 30).

RESULTS

Hospital mortality was 4.7% after subtotal PD and 20% after total PD. Overall 5-year survival was 31%. Survival after PD for ampullary carcinoma care. (5-year, 50%) was significantly better (P < 0.001) than for distal bile duct carcinoma (24%) and pancreatic carcinoma (14%). Independent negative prognostic factors for survival (multivariate analysis) were involved resection margins (hazard rate ratio [HRR] 4.08), major vascular involvement (HRR 2.20), distal bile duct or pancreatic origin of carcinoma (HRR 1.93), and perioperative blood transfusion of more than 4 U (HRR 1.76). Tumor size (> 2 cm), regional lymph node involvement, and a poor differentiation grade were overall negative factors in univariate analysis but not in the subgroup of ampullary carcinoma.

CONCLUSION

Involvement of resection margins, major vascular ingrowth, site of origin of carcinoma, and perioperative blood transfusion were independent prognostic factors for survival after PD. Overall 5-year survival was 31%, and subtotal PD is advocated for all patients with a macroscopically resectable tumor in the pancreatic head region without major vascular involvement, even for those with larger tumors or local lymph node metastasis. Care should be taken to limit the need for perioperative blood transfusions.

Outcome of microscopically nonradical, subtotal pancreaticoduodenectomy (Whipple's resection) for treatment of pancreatic head tumors

From 1983 to 1992 a total of 240 patients with a pancreatic head tumor underwent laparotomy to assess the resectability of the tumor. In 44 patients the tumor was not resected because of distant metastases (n = 20) or major vascular involvement or local tumor infiltration (n = 24) not detected during the preoperative workup. A palliative biliary and gastric bypass was performed in these patients. All other patients underwent a subtotal (Whipple's resection, n = 164) or total (n = 32) pancreaticoduo-denectomy. However, in 56 cases after Whipple's resection, microscopic examination of the specimen showed tumor invasion in the dissection margins. For this reason, these resections were considered palliative. We compared hospital mortality, morbidity, and long-term survival of patients who had undergone a biliary and gastric bypass for a locally advanced tumor (group A, n = 24) with a matched group of patients who had undergone a macroscopically radical Whipple's resection that on microscopic examination proved to be nonradical (group B, n = 36). Both groups were comparable with regard to age (mean 61 years in both groups), duration of symptoms (8 weeks in group A and 10 weeks in group B), and tumor size (mean 4.25 cm in group A and 4.30 cm in group B). Median postoperative hospital stay was 18 days in group A and 25 days in group B. Postoperative complications (intraabdominal abscess, gastrointestinal hemorrhage, anastomotic leakage, delayed gastric emptying) occurred in 33% of patients in group A and in 44% of patients in group B. Hospital mortality was 0% and 3% in group A and group B, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Prognostic factors for survival after pancreaticoduodenectomy for patients with carcinoma of the pancreatic head region

BACKGROUND

The aim of this study was to determine prognostic factors for survival after pancreaticoduodenectomy (PD) for carcinoma of the pancreatic head region.

METHODS

From 1983 to 1992. 176 patients underwent PD for ampullary carcinoma (n = 67), distal bile duct carcinoma (n = 42), or pancreatic carcinoma (n = 67). The first choice for resection was subtotal PD (n = 146), but patients with a tumor-positive pancreatic margin or a brittle pancreatic duct underwent total PD (n = 30).

RESULTS

Hospital mortality was 4.7% after subtotal PD and 20% after total PD. Overall 5-year survival was 31%. Survival after PD for ampullary carcinoma care. (5-year, 50%) was significantly better (P < 0.001) than for distal bile duct carcinoma (24%) and pancreatic carcinoma (14%). Independent negative prognostic factors for survival (multivariate analysis) were involved resection margins (hazard rate ratio [HRR] 4.08), major vascular involvement (HRR 2.20), distal bile duct or pancreatic origin of carcinoma (HRR 1.93), and perioperative blood transfusion of more than 4 U (HRR 1.76). Tumor size (> 2 cm), regional lymph node involvement, and a poor differentiation grade were overall negative factors in univariate analysis but not in the subgroup of ampullary carcinoma.

CONCLUSION

Involvement of resection margins, major vascular ingrowth, site of origin of carcinoma, and perioperative blood transfusion were independent prognostic factors for survival after PD. Overall 5-year survival was 31%, and subtotal PD is advocated for all patients with a macroscopically resectable tumor in the pancreatic head region without major vascular involvement, even for those with larger tumors or local lymph node metastasis. Care should be taken to limit the need for perioperative blood transfusions.

Results of pancreaticoduodenectomy for ampullary carcinoma and analysis of prognostic factors for survival

BACKGROUND

Results of pancreaticoduodenectomy for ampullary carcinoma were evaluated, and prognostic factors for survival were analyzed.

METHODS

During the period from 1984 to 1992 67 patients underwent subtotal or total pancreaticoduodenectomy for ampullary carcinoma. All clinicopathologic data and their influence on survival were studied.

RESULTS

Subtotal pancreaticoduodenectomy was performed in 62 of 67 patients with a mortality of 6% and a morbidity of 65%; the remaining five patients underwent total pancreaticoduodenectomy. Intraabdominal infection was the most important complication. Resection margins were tumor free in 75% of 67 patients. The overall 5-year survival was 50%. Survival was significantly influenced by the involvement of resection margins. After resection with involved margins 5-year survival was 15% and 60% after resection with free margins (p < 0.001). Tumor size, lymph node involvement, and differentiation grade had limited and not significant influence on survival.

CONCLUSIONS

Subtotal pancreaticoduodenectomy is the type of resection of first choice for ampullary carcinoma. Involvement of resection margins was the strongest prognostic factor for survival. Patients with a tumor size larger than 2 cm, with lymph node involvement, or with a poorly differentiated tumor still had a 5-year survival rate greater than 40%. Patients with involved margins might be candidates for studies on adjuvant therapy.

Portal vein resection in patients undergoing pancreatoduodenectomy for carcinoma of the pancreatic head

Of 176 patients with carcinoma of the pancreatic head region 156 underwent standard pancreatoduodenectomy (group 2) and 20 with macroscopic suspicion of invasion of the portal vein or superior mesenteric vein (SMV) underwent pancreatoduodenectomy with partial resection of the portal vein or SMV (group 1). In 16 patients in group 1 end-to-end anastomosis was used for reconstruction of the vein. The morbidity rate in groups 1 and 2 was similar (55 versus 63 per cent). The hospital mortality rate was 15 per cent in group 1 and 7 per cent in group 2 (P = 0.22). Histological examination confirmed tumour invasion of the portal vein or SMV in ten patients in group 1. Invasion of the portal vein or SMV was significantly more frequent in patients with pancreatic cancer than in those with distal bile duct or ampullary carcinoma. Of the 20 patients in group 1 only three underwent curative resection with tumour-free margins. The median survival time after resection of the portal vein or SMV was 8 months; the 2-year survival rate was 19 per cent. Comparison of survival in group 1 with survival in subgroups of patients undergoing standard pancreatoduodenectomy, matched for all histological parameters, showed no significant difference. It is concluded that partial resection of the portal vein or SMV in patients undergoing pancreatoduodenectomy who are suspected of having tumour invasion of the portal vein or SMV does not improve either the rate of curative resection or survival.

Preservation of canine liver grafts using HTK solution

HTK (histidine-tryptophane-ketoglutarate) organ preservation solution has been shown to be effective in human kidney transplantation, but the efficacy of HTK for extended liver preservation has not been determined. In this study, canine livers were preserved in HTK and compared with livers preserved in University of Wisconsin solution. First, the right and left liver lobes in dogs were flushed separately with cold HTK and UW, respectively, according to a double-flush method. After splitting the liver, the right and left lobes were stored at 4 degrees C in either solution for 24 hr and 48 hr and assessed microscopically for parenchymal cell swelling, and enzyme histochemically for 5'-nucleotidase (5'-NT) as a marker of ischemic liver injury. Unlike livers preserved in UW (n = 5), HTK-preserved livers (n = 5) showed progressive parenchymal cell swelling after 24-hr and 48-hr storage. The 5'-NT scores in HTK livers were lower than in UW livers, indicating increased storage injury (0-5% and 66-85% in HTK- and UW-preserved livers, respectively, after 48-hr storage). Second, graft function was tested in an orthotopic liver transplantation model in the dog. Whole livers were flushed in situ with cold HTK or UW and stored at 4 degrees C for 24 hr or 48 hr. Liver grafts stored in HTK were not washed out prior to reflow in the recipient, in contrast to grafts stored in UW. Livers preserved for 24 hr using HTK showed life-supporting function after transplantation (n = 5, survival 12 hr-8 days). All grafts preserved for 48 hr in HTK did not function (n = 5, survival < 10 hr). UW-preserved grafts all functioned after 24-hr storage (n = 5, survival > 6 days), as well as after 48-hr storage (n = 6, survival > 6 days). Peak serum glutamic oxaloacetic transaminase (SGOT) values after transplantation of 24-hr and 48-hr HTK-preserved livers did not differ from peak SGOT values of UW-preserved livers after similar preservation times. In conclusion, UW solution is more effective than HTK solution in extended preservation of canine liver grafts: 24-hr storage of livers preserved with HTK solution is feasible, whereas 48-hr storage results in a nonfunctioning graft.