Prophylactic sequential antibiotic therapy for recurrent liver/biliary sepsis

BACKGROUND AND AIMS

Recurrent liver/biliary sepsis are rare and can occur in different situations. Curative treatment of acute septic episodes is based on antibiotics. Nevertheless, recurrent sepsis can be life-threatening, and the treatment of the underlying disease could be complex, and eventually not possible. The aim of the present study was to report our experience on prophylactic sequential antibiotic therapy for recurrent liver/biliary sepsis in a large cohort of patients with long follow-up.

METHODS

All patients who received a prophylactic sequential antibiotic therapy for recurrent liver/biliary sepsis in our institution from 2005 to 2020 were included. Prophylactic sequential antibiotic therapy was based on per os antibiotics with expected antibacterial activity on digestive bacteria, mainly Gram-negative bacilli. The primary end-point was the reduction of the number of septic episodes to 1 or less episode per year, and not severe (not requiring hospitalization).

RESULTS

Were included 33 adult patients and the main initial disease/condition leading to prophylaxis was history of hepaticojejunostomy (78.8%). The majority of septic episodes required hospitalization (57.6%). First line prophylactic sequential antibiotic therapy was weekly ciprofloxacin in all cases. First line therapy was successful in the long-term in 19 patients (57.6%), with a median follow-up of 92 months (range: 25-206). Global efficacy (first-second-third lines) was 28/33 (84.8%).

CONCLUSIONS

The results of the present study with very long follow-up suggest that prophylactic sequential antibiotic therapy can successfully prevent recurrent liver/biliary sepsis with good tolerance.

Recurrence of Hereditary Hemorrhagic Telangiectasia After Liver Transplantation: Clinical Implications and Physiopathological Insights

Liver transplantation (LT) has been proposed as a curative treatment in hereditary hemorrhagic telangiectasia (HHT) with severe hepatic involvement. We provide a long-term evaluation of graft status after LT for HHT, with a focus on the risk of recurrence. The present study included all patients prospectively followed up after LT for HHT in the Lyon Liver Transplant Unit from 1993 to 2010, with a survival of more than 1 year. Protocol clinical, radiological, and histological examinations were performed at regular intervals. Fourteen patients were included (13 women and one man). Median age at LT was 52.5 years (range: 33.1-66.7). In eight patients (seven female), disease recurrence was diagnosed by abnormal radiological features, suggestive of microcirculatory disturbances. Typical vascular lesions, including telangiectasia, were demonstrated by liver biopsy in five of these patients. The median interval between LT and diagnosis of recurrence was 127 months (range: 74-184). The risk of recurrence increased over time; estimated cumulative risk was 47.9% at 15 years. Liver tissue analysis found the coexistence of an angiogenic process combined with endothelial microchimerism, as shown by the presence of vascular lining cells of recipient origin. Conclusion: The present data show that disease recurrence occurs, usually after a long delay, in a significant number of patients treated by LT for liver complications of HHT. This strongly supports the necessity of a lifelong follow-up and suggests that therapeutic strategy needs discussion and evaluation, especially of the role of potential adjuvant treatments to LT, such as antiangiogenic medications, when recurrent disease appears.

Survival and prognostic factors after adjuvant 131iodine-labeled lipiodol for hepatocellular carcinoma: a retrospective analysis of 106 patients over 20 years

OBJECTIVE

Hepatocellular carcinoma (HCC) has high recurrence rate after curative treatment. The aim of the present study was to report our experience with adjuvant use of ¹³¹I-lipiodol after curative treatment of HCC in terms of recurrence and survival in a large cohort of patients with a long follow-up.

METHODS

All patients treated with ¹³¹I-lipiodol after curative treatment of HCC in two French centers from 1991 to 2009 were included in a retrospective cohort study.

RESULTS

One hundred and six patients were included. The median (range) follow-up was 6 years (0.3-22). Forty-three patients (41%) had cirrhosis. Recurrence-free survival rates at 1, 2, 5, 10, and 20 years were 73, 57, 40, 30, and 14%, respectively. Cirrhosis was an independent predictive factor of recurrence [RR = 1.18, 95% CI (1.11-3.02), p = 0.019]. Overall, survival rates at 1, 2, 5, 10, and 20 years were 90, 83, 59, 37, and 23%, respectively. Prognostic factors were recurrence [RR = 2.73, 95% CI (1.35-5.54); p = 0.005], age over 60 years (RR = 1.91, 95% CI [1.02-3.61]; p = 0.044), and tumor number over 3 [RR = 3.31, 95% CI (1.25-8.77); p = 0.016].

CONCLUSION

Our results suggest that the effect of ¹³¹I-lipiodol after curative treatment of HCC could be related to a beneficial impact on risk factors of early tumor recurrence. This could be evaluated in further studies using modern radioembolization methods.

A simple score for predicting alcohol relapse after liver transplantation: results from 387 patients over 15 years

BACKGROUND

Alcohol relapse can negatively influence the outcome after liver transplantation (LT). The aim of our study was to identify factors that could be associated with the recurrence of harmful alcohol consumption after LT.

METHODS

A total of 387 consecutive patients (23.8% women) who underwent LT for alcoholic cirrhosis in Geneva, Switzerland, and Lyon, France, between 1989 and 2005 were evaluated. Mean +/- SD age was 51.3 +/- 7.5 years. Follow-up time was 61.2 +/- 47.5 months. Alcohol consumption relapse and potential factors associated with it were studied.

RESULTS

The relapse rate of harmful alcohol consumption after LT was 11.9%. In univariate analysis, alcohol relapse was significantly associated with age greater than 50 years (P = .04), year of LT 1995 or earlier (P<.05), duration of abstinence less than 6 months (P = .02), presence of psychiatric comorbidities (P<.001), presence of a life partner (P<.05), and a high score on the High-Risk Alcoholism Relapse (HRAR) scale (P<.001). Multivariate logistic regression disclosed the following independent factors of relapse: duration of abstinence of less than 6 months (odds ratio [OR], 3.3; 95% confidence interval [CI], 1.2-9.3) (P = .02); presence of psychiatric comorbidities (OR, 7.8; 95% CI, 3.1-20.0) (P<.001); and HRAR score higher than 3 (OR, 10.7; 95% CI, 3.8-30.0) (P = .001). In patients with none of these factors, alcohol relapse was 5%, while the presence of 1, 2, or 3 factors was associated with relapse rates of 18%, 64%, and 100% of the patients, respectively.

CONCLUSIONS

In a large cohort of patients undergoing LT for alcoholic cirrhosis, a duration of abstinence of less than 6 months before wait-listing for LT, the presence of psychiatric comorbidities, or an HRAR score higher than 3 was associated with relapse into harmful drinking. The presence of more than 1 factor dramatically increased this risk over 50%. In the pre-LT evaluation in this setting, these factors should be accurately determined.

A simple score for predicting alcohol relapse after liver transplantation: results from 387 patients over 15 years

BACKGROUND

Alcohol relapse can negatively influence the outcome after liver transplantation (LT). The aim of our study was to identify factors that could be associated with the recurrence of harmful alcohol consumption after LT.

METHODS

A total of 387 consecutive patients (23.8% women) who underwent LT for alcoholic cirrhosis in Geneva, Switzerland, and Lyon, France, between 1989 and 2005 were evaluated. Mean +/- SD age was 51.3 +/- 7.5 years. Follow-up time was 61.2 +/- 47.5 months. Alcohol consumption relapse and potential factors associated with it were studied.

RESULTS

The relapse rate of harmful alcohol consumption after LT was 11.9%. In univariate analysis, alcohol relapse was significantly associated with age greater than 50 years (P = .04), year of LT 1995 or earlier (P<.05), duration of abstinence less than 6 months (P = .02), presence of psychiatric comorbidities (P<.001), presence of a life partner (P<.05), and a high score on the High-Risk Alcoholism Relapse (HRAR) scale (P<.001). Multivariate logistic regression disclosed the following independent factors of relapse: duration of abstinence of less than 6 months (odds ratio [OR], 3.3; 95% confidence interval [CI], 1.2-9.3) (P = .02); presence of psychiatric comorbidities (OR, 7.8; 95% CI, 3.1-20.0) (P<.001); and HRAR score higher than 3 (OR, 10.7; 95% CI, 3.8-30.0) (P = .001). In patients with none of these factors, alcohol relapse was 5%, while the presence of 1, 2, or 3 factors was associated with relapse rates of 18%, 64%, and 100% of the patients, respectively.

CONCLUSIONS

In a large cohort of patients undergoing LT for alcoholic cirrhosis, a duration of abstinence of less than 6 months before wait-listing for LT, the presence of psychiatric comorbidities, or an HRAR score higher than 3 was associated with relapse into harmful drinking. The presence of more than 1 factor dramatically increased this risk over 50%. In the pre-LT evaluation in this setting, these factors should be accurately determined.

Negative impact of de novo malignancies rather than alcohol relapse on survival after liver transplantation for alcoholic cirrhosis: a retrospective analysis of 305 patients in a single center

OBJECTIVES

Alcoholic liver disease is a leading indication for liver transplantation (LT). The aim of this study was to evaluate long-term results and survival prognostic factors of LT in this indication from a large cohort of patients.

METHODS

From October 1990 to October 2005, 305 consecutive patients with alcoholic cirrhosis (from 594 patients presenting with cirrhosis, i.e., 51.3%) underwent LT in our center. There were 229 men and 76 women, with a median age of 50 yr (range 30-68). Clinical and biological variables with possible prognostic value were analyzed.

RESULTS

Global survival rate was 92.6% at 1 yr, 88.5% at 3 yr, 84.3% at 5 yr, and 73.4% at 10 yr, and was similar (P=0.78, log-rank test) to that of patients transplanted for other cirrhosis (88.8% at 1 yr, 84.1% at 3 yr, 80.6% at 5 yr, and 74.7% at 10 yr). Recurrence of alcohol consumption was observed in 37 patients (12.1%). De novo cancer occurred in 35 patients after LT (11.5%). Univariate analysis disclosed that male gender, history of smoking, and de novo carcinoma were significant survival prognostic factors (P<0.05, log-rank test).

CONCLUSIONS

Our results strongly confirm that alcoholic liver disease is an excellent indication for LT, but long-term survival is reduced because of other target-organ damage of both alcohol and tobacco, especially aero-digestive malignancies, which are greater causes of morbidity and mortality than is recurrent alcohol liver disease.

Rejection under alpha interferon therapy in liver transplant recipients

Interferon alpha (IFN) is the corner stone drug for the treatment of recurrent hepatitis C (HCV) in liver transplant (LT) recipients. One of its serious potential adverse effects is acute and chronic rejection. The aim of this study was to review our experience using IFN-based therapy, in order to examine the incidence and the risk factors for rejection, and the outcome of patients who developed rejection. Between September 1990 and December 2004, 70 LT recipients were treated. Patients started antiviral treatment 16 (1-137) months after LT. Histological follow-up was available in all patients according to protocol biopsies. Rejection was diagnosed and graded according to Banff classification. Twenty-one percent of patients developed acute rejection (5 mild, 9 moderate and 1 severe) during IFN-based therapy. Patients were treated for 8 (1-15) months prior to rejection. Previous history of acute rejection before IFN therapy and treatment with pegylated-IFN was significantly associated with rejection (p = 0.04 and p = 0.02, respectively). The rejection was successfully treated in 87% of patients. No chronic rejection or graft losses were observed. Acute rejection under IFN-based therapy often occurs in LT recipients, but early diagnosis with protocol biopsies and early treatment can lead to a favorable outcome.

Unresectable hepatocellular carcinoma: survival and prognostic factors after lipiodol chemoembolisation in 89 patients

BACKGROUND

The majority of patients with hepatocellular carcinoma are not eligible for surgical radical treatment (resection or liver transplantation) and lipiodol chemoembolisation is an efficient alternative procedure in this indication.

AIMS

To identify prognostic factors in patients treated with lipiodol chemoembolisation.

PATIENTS AND METHODS

During 10 years, 89 consecutive patients with unresectable hepatocellular carcinoma underwent lipiodol chemoembolisation as a single treatment. There were 80 males and 9 females, with a median age of 65 years. Treatment consisted of one to six courses of hepatic intra-arterial lipiodol with doxorubicine and gelatin sponge.

RESULTS

The median survival was 13 months with a 13.6% survival rate at 4 years. Univariate analysis showed that serum levels of albumin, bilirubin, alkaline phosphatase and alpha-fetoprotein, Child's class, tumour type, tumour size and intensity of lipiodol capture after the first course of lipiodol chemoembolisation were significant prognostic factors of survival. In the multivariate analysis, four parameters remained associated with a significantly better outcome: Child's class A, largest lesion<5 cm, uninodular tumour and intense lipiodol capture.

CONCLUSIONS

While lipiodol chemoembolisation is associated with good results only in some patients, in the absence of lipiodol capture, it should be ruled out.

Diagnosis and treatment of biliary obstruction caused by portal cavernoma

While hemorrhagic complications of portal cavernoma are frequent, compression of the bile ducts by portal cavernoma is uncommon and treatment is still a matter for debate. We report here six new cases in order to describe: (a) the clinical, biological, and morphological features of this condition, and (b) the long-term results of a combined endoscopic and surgical treatment. The median age of patients at the time of diagnosis was 36.5 years. The circumstances of diagnosis were acute cholangitis (n=3), asymptomatic biological cholestasis (n=1), pruritus, jaundice and asthenia (n=1) and jaundice alone (n=1). Portal cavernoma and bile duct dilatation were confirmed by abdominal ultrasonography with pulsed color doppler and endoscopic retrograde cholangiography (ERC). Gallstones were found in four patients. Following stenting of the bile duct, there was a good outcome in two patients. In four patients, after failure of prolonged endoscopic treatment, second-line surgical portal-systemic shunting allowed removal of the biliary stent, and no recurrence of disease. In conclusion, biliary involvement in portal cavernoma is now a well-recognized entity, and our results suggest that combined endoscopic and surgical treatment could be required.

Endothelial cell marker expression in dysplastic lesions of the liver: an immunohistochemical study

BACKGROUNDS/AIMS

Hepatocellular carcinoma usually contains continuous capillary vessels lacking the differentiation markers specific for normal sinusoidal endothelial cells. We therefore aimed to search for alterations in endothelial cell marker expression in precancerous liver lesions.

METHODS

Expression of the endothelial cell markers CD31, CD34 and BNH9 was analyzed in 138 dysplastic lesions from 40 cirrhotic patients (20 with and 20 without hepatocellular carcinoma).

RESULTS

No expression of the three endothelial cell markers was detected in cirrhotic nodules and in non dysplastic regenerative macronodules. The three markers were detected in 29.8% of dysplastic lesions and 47% of hepatocellular carcinomas. At least one marker was detected in 75% of dysplastic lesions and 100% of hepatocellular carcinomas. The three markers were more frequently expressed in areas of small cell than of large cell change (34 vs 10%). No correlation was found with the grade of dysplasia, the occurrence of arterialization and the association with hepatocellular carcinoma.

CONCLUSIONS

Alterations in the hepatic microcirculation comparable to those observed in hepatocellular carcinoma are present in a significant proportion of dysplastic lesions of the liver and may be indirect markers of the process of liver carcinogenesis.

Transjugular intra-hepatic portosystemic shunt for refractory variceal bleeding

BACKGROUND

The most dramatic complication of portal hypertension in cirrhotic patients is oesophageal variceal bleeding. Moreover, patients with bleeding unresponsive to medical and endoscopic treatment have a poor prognosis.

OBJECTIVE

The aim of this study was to evaluate the efficacy of early transjugular intra-hepatic portosystemic shunt (TIPS) in patients with refractory variceal bleeding.

PATIENTS AND METHODS

TIPS was performed for 28 patients (17 were stage Child C), successfully in 26. Variceal bleeding was controlled in all but one successfully stented patient.

RESULTS

There was no mortality associated with the procedure. The two patients with a failure of TIPS insertion died of persistent bleeding in the first 48 h after failed TIPS. The 40-day mortality rate was 25%. Five patients died (one from persistent bleeding from gastric varices and four from multi-organ failure). Using multivariate analysis, the only independent factor associated with early mortality was the total bilirubin value. Fifteen surviving patients were listed for liver transplantation: four deaths occurred, eight patients were transplanted in the 6 months after TIPS and three are still waiting. Among the six patients who survived but were ineligible for transplantation, two died and four are still alive. Two episodes of early rebleeding and eight of late rebleeding occurred. Actuarial survival was 75% at one year and 52% at two years.

CONCLUSIONS

Early TIPS is an effective rescue therapy for controlling refractory variceal bleeding.

Orthotopic liver transplantation for idiopathic portal hypertension: indications and outcome

BACKGROUND

Idiopathic portal hypertension is a rare clinical syndrome which may be associated with a spectrum of histological lesions, including nodular regenerative hyperplasia and incomplete septal cirrhosis. Here, we report eight adult patients with idiopathic portal hypertension who experienced an unusually severe clinical evolution characterized by the development of progressive hepatic failure requiring orthotopic liver transplantation. Our aims are: (a) to stress the distinctive clinical presentation of these patients, (b) to describe their biological and histopathological features, and (c) to evaluate the results of orthotopic liver transplantation in this rare indication.

METHODS

Complete clinical charts and histological data were available in all patients. All patients were male. Their age at diagnosis ranged from 17 to 59 years. Complications of portal hypertension revealed the disease in all cases. Medical treatment was performed in all patients and portosystemic shunt in three.

RESULTS

The development of progressive hepatic failure led to the indication of liver transplantation after a delay ranging from 3 to 10 years. Explanted livers showed pure nodular regenerative hyperplasia in three patients and incomplete septal cirrhosis in five. Recovery was uneventful. All patients are alive, without recurrence of the disease.

CONCLUSIONS

This report points to the existence of severe cases of idiopathic portal hypertension occurring without underlying or associated systemic disease and characterized by a poor clinical course and requiring liver transplantation.

Intra-arterial iodine 131-labeled lipiodol as adjuvant therapy after curative liver resection for hepatocellular carcinoma: a phase 2 clinical study

HYPOTHESIS

Intra-arterial lipiodol labeled with iodine 131 ((131)I-lipiodol) can be safely used as adjuvant therapy following curative liver resection for hepatocellular carcinoma (HCC).

DESIGN

Phase 2 pilot study.

SETTING

Large teaching hospital.

PATIENTS

Twenty-eight patients (24 men and 4 women; median age, 61.5 years; range, 33-75 years) were treated from January 1991 to June 1997. The liver was cirrhotic in 7 cases and noncirrhotic in 21 cases. An equal number of 14 patients underwent a major and a minor resection, all with clear margins. Median diameter of solitary tumors or the larger tumor when multiple tumors occurred was 5.5 cm (range, 2.5-29 cm). Tumor encapsulation was present in 12 cases and absent in 16 cases. After informed consent, patients who had no evidence of residual or recurrent tumor on computed tomographic (CT) scan and no sign of liver failure 2 to 3 months after curative resection for HCC were included in the trial. Complete follow-up was obtained (median, 51 months; range, 5-93 months).

INTERVENTIONS

A 1110-MBq dose of (131)I-lipiodol was administered into the hepatic artery using the Seldinger technique. Patients were kept in a radio-protected room for 5 days. Postinjection radioactive whole scintiscan was performed at 5 days and an abdominal CT scan at 1 month after the injection. A second injection was performed in 16 patients 2 years later using the same protocol.

MAIN OUTCOME MEASURE

Procedure safety.

RESULTS

All patients experienced transient fever during the first 12 hours following injection. There were no noted adverse clinical effects or significant alteration in hepatic function due to the procedure or at immediate and late follow-up. The radioactive scan demonstrated an intense liver uptake, which was homogeneous in 19 cases and heterogeneous in 9. Mild detectable thyroid and lung uptake occurred in 50% of cases. No lipiodol liver fixation was observed on the 1-month CT scan. At the time of follow-up, 6 patients had died and 12 had developed recurrences, with 5 of the 6 deaths belonging to the recurrent group. Sixteen patients remained disease free. The median time to detected recurrence was 28 months (range, 12-62 months). Overall survival rates were 86% at 3 years and 65% at 5 years.

CONCLUSIONS

This pilot study failed to demonstrate any clinically significant adverse effect of adjuvant therapy by intra-arterial (131)I-lipiodol after curative liver resection for HCC. Long-term survival compares favorably with those undergoing only surgery and suggests a benefit in lowering tumor recurrence. A randomized, multicenter, prospective trial comparing patients treated with intra-arterial (131)I-lipiodol with a nontreated control group seems appropriate.

[Late cryptococcal meningitis after liver transplantation]

We report a case of cryptococcal meningitis, eight years after liver transplantation for primary biliary cirrhosis. Detection of the cryptococcal antigen in serum and cerebrospinal fluid appears to be essential for initial diagnosis and follow-up. Oral fluconazole treatment alone can be effective, when given for a very long period to prevent relapse.

Familial occurrence of nodular regenerative hyperplasia of the liver: a report on three families

BACKGROUND/AIMS

Nodular regenerative hyperplasia of the liver is a histological lesion usually associated with systemic diseases, haematological malignancies, or drugs. Its prognosis depends on portal hypertension, which usually is well tolerated and requires medical management only.

PATIENTS

Three unrelated families, in which two sibling adult male patients presented with nodular regenerative hyperplasia of the liver, were studied.

METHODS

Complete clinical charts and liver biopsy specimens were available for all patients. In addition, explanted livers were available for examination for the two transplanted patients.

RESULTS

There was no evidence of any of the various clinical situations known to be associated with nodular regenerative hyperplasia of the liver. Portal hypertension was severe, requiring surgical treatment in two cases. Renal lesions were present in three patients. In two patients, progressive evolution to liver atrophy and hepatic failure, associated with renal failure, led to combined liver and renal transplantation.

CONCLUSIONS

This report describes the existence of familial cases of nodular regenerative hyperplasia of the liver, occurring without underlying or associated systemic disease, characterised by a poor clinical course and often associated with progressive renal failure.

[The Budd-Chiari syndrome (hepatic vein obstruction). The diagnostic and therapeutic management of acute and subacute forms]

EARLY DIAGNOSIS: The Budd-Chiari syndrome results from an obstruction of the suprahepatic venous drainage. The condition spontaneously evolves towards liver fibrosis and death. Early diagnosis is thus of prime importance to initiate adapted treatment promptly.

EXPLORATIONS

Color-coded and pulsed Doppler coupled with ultrasonography is the key to positive diagnosis. Magnetic resonance imaging may provide further precision. DECONGESTION OF THE LIVER: As the hepatic lesions are reversible, satisfactory drainage must be achieved as rapidly as possible, either by percutaneous puncture or surgery. The problem is to control the underlying hematology disease to prevent recurrent venous thrombosis, generally the cause of treatment failure. PREVENTIVE ANTICOAGULATION: Effective anticoagulation using low-molecular-weight heparin, which appears to be more adapted than standard heparin, must be achieved prior to any decongestion procedure. Long-term management requires anti-vitamin K therapy if the risk of thrombosis persists.

Prospective evaluation of transnasal esophagogastroduodenoscopy: feasibility and study on performance and tolerance

BACKGROUND

With a pediatric endoscope, esophagogastroduodenoscopy (EGD) can be performed via a nasal route in adults. To evaluate this new procedure, we conducted a randomized comparative study of the feasibility of diagnostic transnasal EGD and assessed the factors influencing its quality and tolerance (endoscope diameter or route).

METHODS

Transnasal EGD was attempted in 100 patients to assess its feasibility. For the analysis of quality and tolerance, 150 patients were randomized as follows into 3 groups according to the route of examinations: (1) oral route with 9.8 mm diameter standard videoendoscope; (2) oral route with 6.0 mm diameter pediatric videoendoscope; (3) transnasal route with 6.0 mm diameter pediatric videoendoscope. The operator assessed the quality of examination by standard scores. Patients quantified pain intensity, nausea, and choking sensation.

RESULTS

Transnasal EGD was feasible in 82% of patients. The quality of the examination was significantly lower with pediatric endoscope. No difference was noted concerning pain intensity, but nausea and choking sensation were significantly reduced when the nasal route was used.

CONCLUSIONS

Transnasal EGD is feasible in the routine practice of diagnostic EGD. The nasal route, and not endoscope diameter (6.0 mm vs 9.8 mm diameter), is the determining factor that explains increased patient tolerance during transnasal EGD. Technical improvements in pediatric videoendoscopes are required.

Liver transplantation resolves the hyperdynamic circulation in hereditary hemorrhagic telangiectasia with hepatic involvement

BACKGROUND & AIMS

Hepatic involvement in hereditary hemorrhagic telangiectasia is common but often asymptomatic. However, in some cases, the vascular lesions that involve the liver may lead to high-output cardiac failure and pulmonary hypertension that is predominant over hepatobiliary manifestations. Liver transplantation and treatment of these complications are described and discussed in this article.

METHODS

Three patients with hereditary hemorrhagic telangiectasia and hepatic involvement received transplants. They had pulmonary hypertension and chronic right-sided heart failure caused by disseminated intrahepatic telangiectasias with shunts between the hepatic artery and hepatic veins or portal vein. Left-to-right intrahepatic shunt output was estimated to range between 51% and 57.5% of cardiac output.

RESULTS

Hyperdynamic circulation disappeared after liver transplantation in all patients. Results of computed tomography and right-sided heart catheterization performed 6 months later were normal. Follow-up periods currently are 65, 53, and 29 months, and each patient continues to be asymptomatic.

CONCLUSIONS

This report suggests that liver transplantation can be considered as an alternative and successful curative treatment that may prevent the irreversible evolution of cardiopulmonary disease.

Reversal of early acute rejection with increased doses of tacrolimus in liver transplantation: a pilot study

BACKGROUND

In this pilot study, we present the results of treatment of early (3 months after liver transplantation) acute rejection episodes by increasing only the tacrolimus doses.

METHODS

Ten patients who received tacrolimus as primary treatment experienced acute mild (one case), moderate (four cases), or severe (five cases) rejection episodes. Tacrolimus dosing was increased 1-2 mg every 1 or 2 days until hepatic enzymes started to improve. Steroid basic daily doses were kept unchanged.

RESULTS

With the daily dose of tacrolimus increased by a median 1.89-fold (range: 1.2-5), alanine aminotransferase, bilirubin, and gamma-glutamyltranspeptidase levels rapidly reached normal values within the first month. During a median follow-up time of 19.5 months (range: 14-24), none of the 10 patients died or lost their graft. Control liver biopsies were done 13.5 months (range: 7-19) after rejection episode in all patients, and none demonstrated evidence of rejection or sequela.

CONCLUSION

This pilot study suggests that increasing tacrolimus dosage could be considered as treatment against early acute rejection episodes including the severe grade.

[Adrenal metastases of hepatocellular carcinoma. Therapeutic options]

AIM OF THE STUDY

The aim of this study was to evaluate the therapeutic modalities, particularly surgical treatment, for adrenal metastasis of hepatocellular carcinomas.

PATIENTS AND METHODS

This series included 13 patients (mean age: 64 years) with hepatocellular carcinoma on cirrhotic liver (n = 8) or healthy liver (n = 5). The adrenal metastasis was synchronous in four cases, metachronous in nine, unilateral in ten cases, and bilateral in three. Resection of the adrenal metastasis was performed in seven patients, combined with the resection of the hepatic carcinoma in three cases or secondarily performed in four. The metastasis was not resected in six patients because of poor liver function or poor patient conditions; two patients were treated with percutaneous ethanol injection, one with radiation and three received only a symptomatic treatment.

RESULTS

After adrenalectomy combined with liver resection, two patients died in the postoperative course in relation with pulmonary embolism (n = 1) or acute pancreatitis (n = 1). The mean survival in the five other patients was 38 months after the adrenalectomy and 58.6 months after the liver resection. After percutaneous ethanol injection, one patient survived 47 months and the other one 7 months only. After radiation, the patient survived 18 months. After symptomatic treatment, the mean survival was only 7.3 months.

CONCLUSION

The present data suggest that adrenal metastasis, either isolated or associated with a well-controlled intrahepatic recurrence, could be treated surgically when the resection is technically feasible. This aggressive management seems the only chance to offer a long-term survival to selected patients.

Primary hepatocellular carcinoma in workers exposed to vinyl chloride: a report of two cases

BACKGROUND

Vinyl chloride (VC), an industrial toxic gas, has a dose-dependent carcinogenicity in rodents and has been responsible for multiple cases of liver angiosarcoma in humans. The aim of this study was to describe histopathologic liver alterations and to evaluate risk factors for hepatocellular carcinoma in two workers from the same plant, both of whom had primary nonangiosarcoma liver tumors and were exposed to VC.

METHODS

Clinical, biochemical, serologic, and pathologic data were reviewed at the time of hepatic resection. Clinical and biologic follow-up were available for several years before the diagnosis of hepatocellular carcinoma.

RESULTS

Liver alterations distant from the tumor site were compatible with ongoing exposure to VC in both cases. Several areas containing dysplastic hepatocytes were present in nontumoral liver in one patient. Both patients are alive after partial liver resection, and 1 has had 5 years of follow-up without recurrence.

CONCLUSIONS

Exclusion of classic risk factors for noncirrhotic hepatocellular carcinoma of the liver in both patients suggests a relationship between VC exposure and observed tumors. Systematic long term follow-up with biology and ultrasonography for workers exposed to VC may result in relatively early diagnoses of liver tumors and long term survival in some cases.

Adult cirrhotic liver explants: precancerous lesions and undetected small hepatocellular carcinomas

BACKGROUND & AIMS

Despite recent advances in imaging techniques of the liver, it remains difficult to detect small precancerous lesions or hepatocellular carcinomas (HCCs) in cirrhotic livers. The goal of this study was to determine the prevalence of undetected small HCCs in liver explants of adult cirrhotic patients undergoing liver transplantation and to evaluate the association of HCCs with hepatic lesions considered premalignant.

METHODS

Eighty consecutive liver explants were analyzed for the presence of macroscopically atypical nodules, which were then pathologically described as macroregenerative nodules, high-grade dysplastic nodules, areas of small liver cell dysplasia, and HCCs.

RESULTS

The prevalence of HCC was 17.5% with a mean size of 11.6 mm. HCCs were more frequently found in men (22%) than in women (4.8%; P < 0.05) and in patients older than 50 years at the time of liver transplantation (35.7% vs. 7.7% in patients younger than 50 years; P < 0.05). The prevalence of HCCs was identical in alcoholic and viral cirrhosis. HCC nodules were significantly associated with the presence of high-grade dysplastic nodules.

CONCLUSIONS

Small HCCs and precancerous lesions are frequently found in cirrhotic liver explants, especially in men older than 50 years. This finding should be included in the decision-making analysis for liver transplantation.

Effectiveness of early alpha-interferon therapy for hepatitis C virus infection recurrence after liver transplantation

The results in this short series show that early and prolonged alpha-interferon therapy for hepatitis C virus recurrence after liver transplantation could bring some benefit to the infected liver grafts. The risk of graft rejection was clearly minimised by maintaining immunosuppression at normal levels.

Endoscopic stenting for pain relief in chronic pancreatitis: results of a standardized protocol

BACKGROUND

Pancreatic endoscopic stenting aims to relieve abdominal pain due to chronic pancreatitis. Optimal treatment modalities and post-treatment effects have still to be determined. The object of this study was to investigate the results of a standardized protocol of endoscopic stenting.

METHODS

Twenty-three patients with abdominal pain due to chronic pancreatitis and stricture of the distal main pancreatic duct were treated according to the following protocol: after balloon dilation of the stenosis, a 10F stent was placed into the main pancreatic duct and then exchanged every 2 months, the total duration of drainage being 6 months.

RESULTS

Use of analgesics could be discontinued in 17 patients (74%) on termination of drainage, and in 12 patients (52%) 1 year later. These results were significantly associated with reduction of main pancreatic duct diameter and resolution of stricture, but were not influenced by abstinence from alcohol and pancreatic enzyme supplementation.

CONCLUSIONS

Pancreatic duct stenting results in short-term clinical improvement in patients with chronic pancreatitis and proximal main pancreatic duct stricture. Persistence of advantageous clinical results is to be expected in 50% of cases and when strictures have resolved.

Aminopyrine breath test: development of a 13C-breath test for quantitative assessment of liver function in humans

BACKGROUND/AIM

14C-aminopyrine breath test (ABT) has been shown to be well correlated to the severity of liver diseases, but its use is limited in countries where radioactive isotopes are severely controlled. The goal of this study was to develop a 13C-ABT based on a highly sensitive method to measure 13CO2 in breath samples.

MATERIALS AND METHODS

The relevant parameters were studied in 26 controls and 27 patients: the 13CO2 enrichment of expired breath between t-10 and t+60 minutes was determined as the most simple and clinically useful parameter. The 13C-ABT was then prospectively compared to clinico-biological data and the galactose elimination capacity (GEC) in 82 patients.

RESULTS

The 13C-ABT was well correlated to: i) the Child-Pugh classification; ii) GEC results; iii) the hepatic volume. The presence of ascites or alcoholic consumption did not alter significantly the results of the test. 13C-ABT appeared more sensitive than GEC to evaluate minor liver dysfunctions.

CONCLUSIONS

The 13C-ABT is a simple and sensitive test to measure liver function. The use of the stable isotope 13C ensures the harmlessness of the test and the possibility to repeat it in a given patient.

[Liver transplantation for alcoholic liver disease. Selective indications]

Alcoholic liver disease represents about 15% of all indications for liver transplantation. Patient selection is difficult, and must be rigorous. Peri-operative risks are evaluated on the same basis as for other chronic liver diseases, with special attention for alcoholic extra-hepatic morbidity and nutritional status. Definite withdrawal from alcohol is mandatory. Predictive factors of long-term abstinence are the absence of psychopathologic state, an adequate social and affective situation, the possibilities of professional reinsertion, and a strong motivation of the patient towards liver transplantation. A six-month period of complete abstinence before registration on a liver transplantation waiting list is not mandatory, although intermittent alcoholic abuse before transplantation should be an exclusion factor. Liver transplantation must be proposed based on the severity of liver failure, as assessed by pronostic scores. It must be rapidly discussed following an acute episode of decompensation, in the absence of a significant improvement despite adequate medical therapy. It must also be discussed for long-term abstinent patients, with an apparently stabilized cirrhosis, but with an important decrease of the functional liver mass. The evaluation of the functional liver mass is based upon the Child-Pugh score, associated with the results of metabolic liver function tests, the measurement of the hepatic volume and the severity of portal hypertension.

[Mid-term failure of balloon dilatation treatment of antral stenosis induced by caustics]

We report the case of an antral stricture following lye ingestion. The patient was treated by 3 dilations using a through-the-scope balloon dilator, initially with good results. One year later, the recurrence of the symptoms led to 2 other sessions of dilation without success and a partial gastrectomy was performed. The intensity of the gastric wall fibrosis on the surgical specimen, probably responsible for major motor impairment, accounts for the discordance between the good endoscopic result and the clinical failure. Endoscopic dilation of lye-induced gastric strictures could be a temporary alternative to surgical resection because the gastric wall fibrosis blemishes the long-term functional result.

Hepatic involvement in hereditary hemorrhagic telangiectasia: clinical, radiological, and hemodynamic studies of 11 cases

BACKGROUND

Hepatic involvement in hereditary hemorrhagic telangiectasia (HHT) is infrequent and poorly studied. The aim of this study was to describe the clinical, radiological, and hemodynamic patterns of this involvement.

METHODS

Eleven consecutive patients with HHT and hepatic involvement observed within 12 years were retrospectively studied. They were 8 females and 3 males, mean age, 47.

RESULTS

The patients presented with heart failure (4 cases), hepatomegaly and murmur of the right hypochondrium (7 cases), and digestive hemorrhage (6 cases). Eight patients had anicteric cholestasis. Celiac angiography showed a dilated hepatic artery in 8 cases, disseminated intrahepatic telangiectasias in 10, and early opacification of the hepatic veins in 7. Liver dynamic computed tomography (CT) scan performed in 7 patients allowed the diagnosis of liver involvement in each case. Hemodynamic studies were performed in 5 patients. A left-to-right intrahepatic shunt was proven in the 5 patients. Shunt output was estimated between 25% and 58% of cardiac output. Mild pulmonary hypertension was observed in the 5 cases.

CONCLUSIONS

Diagnosis of liver involvement in HHT can be made by dynamic CT scan or celiac angiography. The main feature of this involvement is high output heart failure due to left-to-right intrahepatic shunt. Thus, right-heart catheterization is necessary in these patients to confirm and evaluate the shunt.

[Veno-occlusive disease after liver transplantation. Association of acute cellular rejection and toxicity of azathioprine]

Azathioprine vascular hepatotoxicity has been described mainly after renal transplantation. We report a new case in a patient who developed veno-occlusive disease of the liver 3 weeks after liver transplantation; regression of lesions were observed after discontinuation of azathioprine therapy. In this case, azathioprine hepatotoxicity may have been enhanced by a previous episode of severe, acute rejection prevailing in the hepatic veins. After liver transplantation, the diagnosis of azathioprine hepatotoxicity is difficult but should be suspected in the presence of non-inflammatory small hepatic veins lesions. Early withdrawal of the drug is mandatory for complete recovery.

Liver transplantation for erythropoietic protoporphyria. Report of a new case with subsequent medium-term follow-up

We report a new case of successful liver transplantation in a 36-year-old patient with terminal hepatic failure due to erythropoietic protoporphyria. Data regarding protoporphyrin levels in erythrocytes and feces, before and after transplantation, seem to indicate that in this case protoporphyrin overproduction was in part due to liver synthesis. Four years after surgery, the patient is completely free of skin photosensitivity. His liver function tests are normal; there are no visible protoporphyrin deposits or ultrastructural abnormalities in his new liver. However, recurrence of the disease in the long term cannot be excluded, since erythrocyte protoporphyrin levels remained elevated after liver transplantation.

Radical and nonradical hepatic resection for alveolar echinococcosis: report of 18 cases

The authors report their experience with 18 patients who underwent liver resection for alveolar echinococcosis of the liver from June, 1982 to January, 1989. Preparation for surgery included transhepatic biliary external-internal drainage in order to alleviate jaundice in 8 cases and catheterization of infected necrotic cavities in 7 cases. Resection was radical in 9 patients who underwent either right lobectomy (5 cases) or right trisegmentectomy (4 cases) with "en bloc" extension to the bifurcation of the hepatic ducts in 3 cases. Resection was nonradical in another group of 9 patients who had either atypical right hepatectomy (6 cases) or atypical left hepatectomy (3 cases). All patients were submitted to a periodic follow-up. The 9 patients treated by radical resection are alive and symptom-free and appear to be disease-free at radiologic imaging, except for 1 patient who had a small area of parasitic recurrence on computed tomography scan 4 years after operation. Among the 9 patients treated by palliative resection, 3 patients died during the follow-up period, the cause of the death having been related to the disease in 2 cases and nonrelated in 1 case. The 6 surviving patients had no noticeable growth of the parasitic mass during the period of follow-up. When feasible, radical liver resection is the best form of therapy. When massive parasitic invasion of both lobes of the liver and the porta hepatis and vena cava precludes radical hepatectomy, palliative resection associated with percutaneous procedures has to be considered before embarking on orthotopic liver transplantation.

[Outcome of patients after treatment of esophageal varices by endoscopic sclerotherapy]

One hundred and forty-one patients (100 males, mean age 56.8 +/- 11 years) with a previous bleeding episode from ruptured esophageal varices were followed prospectively after obliteration of varices by elective endoscopic sclerotherapy. Eighty two p. 100 had alcoholic cirrhosis, 30 p. 100 were Child Pugh class A, 60 p. 100 B, 10 p. 100 C. Median follow up period was 16 months. Endoscopic control was carried out on a three month schedule. Compliance was perfect in 81 p. 100 of cases. Recurrent varices developed in 58 patients within a mean (+/- SD) delay of 6.8 +/- 4.7 months. One to 2 sclerotherapy sessions were required to obliterate recurrent varices without serious complications. The frequency of variceal recurrence was significantly lower (p less than 0.001) in case of alcohol with arawal. Five patients (3.5 p. 100) presented a recurrence of variceal bleeding which was fatal in 3 cases. During the follow up period, there were 25 deaths (17.7 p. 100). Survival was significantly correlated to the Child Pugh class (p less than 0.02) and significantly increased in the group of patients who adhered to the protocol (p greater than 0.05). These results suggest that after obliteration of varices patients should be submitted to a trimestrial endoscopic control during the first year, the subsequent schedule being determined by the recurrence of varices during the first year. Endoscopic and clinical follow up of patients, which facilitates alcohol with arawal, could have a favorable effect on the course of hepatic disease.

Hepatocellular carcinoma: diagnosis by percutaneous fine needle biopsy

One hundred fifty-nine cases of hepatocellular carcinomas (HCCs) were reviewed from a series of 1060 cases of percutaneous fine needle biopsies of the liver. The biopsies were performed under ultrasonic guidance using a 22-gauge needle with a beveled tip. Specimens were obtained from the lesion and from areas of normal-appearing liver for comparison. Two sets of slides were prepared for Papanicolaou and Giemsa staining. In 147 cases (92%), the diagnosis of malignancy was established. In 134 cases (84%), the specific diagnosis of HCC was made. Fifty-four percent of the HCCs were well differentiated without cytonuclear abnormalities. In these cases, the diagnosis was made by comparison of specimens from the tumor with those obtained from the normal liver. Thirty-seven percent of the HCC were moderately differentiated with cytonuclear abnormalities. Nine percent of the HCCs were poorly differentiated, and in these cases, identification of glycogen on periodate-Schiff's procedure staining permitted differentiation from a metastatic tumor. In 9 cases, the aspirate was inadequate: there was insufficient tissue in 3 cases and the lesion was missed in the 6 other cases. In 3 cases, a biopsy of normal liver was not obtained and the diagnosis of HCC could only be suspected. Significant bleeding after biopsy occurred in 4 of 1060 cases, all with HCC.

[Autoimmune hemolytic anemia during treatment with cyclosporin after liver transplantation]

Hemolytic anemia was observed in a 36 year-old liver transplant patient. The immunosuppressive regimen included cyclosporine A and prednisolone. Hemolysis appeared a few days after amoxicillin treatment. The presence of anti-D allo-antibodies, auto-antibodies active against erythrocytes, and an immuno-allergic phenomenon against erythrocytic membrane coated by cyclosporine was demonstrated. Increase of daily dose of prednisolone without modification of cyclosporine doses was followed by the disappearance of allo- and auto-sensitization. The role of amoxicillin in promoting these hemolytic phenomenons may be suggested.

[Treatment of hepatic polycystosis by intracystic injection of alcohol]

Two patients with symptomatic polycystic liver disease were treated with aspiration and injection of alcohol into the cyst cavities. Only the cysts larger than three to five centimeters were treated. No complications were encountered. Transient pain was observed in one case. There was no recurrence of the treated cysts on follow-up examinations at five to 74 months. These results suggest that aspiration and injection of alcohol is an effective treatment for symptomatic polycystic liver disease.