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D'Amico G, Tarantino G, Spaggiari M, Ballarin R, Serra V, Rumpianesi G, Montalti R, De Ruvo N, Cautero N, Begliomini B, Gerunda GE, Di Benedetto F. Multiple ways to manage portal thrombosis during liver transplantation: surgical techniques and outcomes. Transplant Proc 2013; 45:2692-9. [PMID: 24034026 DOI: 10.1016/j.transproceed.2013.07.046] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Portal vein thrombosis (PVT) is a well-recognized complication of chronic liver disease with a prevalence ranging from 1% to 16%. MATERIALS AND METHODS We performed a retrospective review of 447 consecutive patients who underwent liver transplantation (OLT) between October 2000 and December 2011 comparing 51 recipients with PVT (study group) with 399 without PVT (control group). The aim of this study was to determine the impact of pre-existent PVT on the surgical procedure, to identify specific preventable perioperative complications, and based on our studies and other works, to determine whether this group of patients are acceptable candidates for OLT. RESULTS Among the 51 patients with PVT, 44 showed partial and 7 complete thrombosis. In 47 cases, we performed a thromboendovenectomy. There were six anastomoses at the confluence of the superior mesenteric vein (SMV) and one, with a venous graft interposition. In four complete thrombosis recipients we performed an extra-anatomic by pass between the main trunk of the SMV and the donor portal vein. Compared with the control group, regarding preoperative characteristics, PVT patients were older at the time of transplantation (P = .001) and had a higher use of TIPS (P = .02). The operative characteristics showed a longer warm ischemia time in the PVT group (46.9 ± 22.5 vs 39.3 ± 15 min; P = .004). There were significant differences in postoperative evaluations, nor in the complication rates. Overall survivals at 10 years were similar: 61.7% versus 65.3%; (P = .9). CONCLUSION Although PVT was associated with greater operative complexity, it had no influence on postoperative complications or overall survival.
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Affiliation(s)
- G D'Amico
- Hepato-Biliary-Pancreatic Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
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Masetti M, Montalti R, Rompianesi G, Codeluppi M, Gerring R, Romano A, Begliomini B, Di Benedetto F, Gerunda GE. Early withdrawal of calcineurin inhibitors and everolimus monotherapy in de novo liver transplant recipients preserves renal function. Am J Transplant 2010; 10:2252-62. [PMID: 20486905 DOI: 10.1111/j.1600-6143.2010.03128.x] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We designed a randomized trial to assess whether the early withdrawal of cyclosporine (CsA) followed by the initiation of everolimus (Evr) monotherapy in de novo liver transplantation (LT) patients would result in superior renal function compared to a CsA-based immunosuppression protocol. All patients were treated with CsA for the first 10 days and then randomized to receive Evr in combination with CsA up to day 30, then either continued on Evr monotherapy (Evr group) or maintained on CsA with/without mycophenolate mofetil (CsA group) in case of chronic kidney disease (CKD). Seventy-eight patients were randomized (Evr n = 52; CsA n = 26). The 1-year freedom from efficacy failure in Evr group was 75% versus 69.2% in CsA group, p = 0.36. There was no statistically significant difference in patient survival between the two groups. Mean modification of diet in renal disease (MDRD) was significantly better in the Evr group at 12 months (87.7 ± 26.1 vs. 59.9 ± 12.6 mL/min; p < 0.001). The incidence of CKD stage ≥ 3 (estimated glomerular filtration rate < 60 mL/min) was higher in the CsA group at 1 year (52.2% vs. 15.4%, p = 0.005). The results indicate that early withdrawal of CsA followed by Evr monotherapy in de novo LT patients is associated with an improvement in renal function, with a similar incidence of rejection and major complications.
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Affiliation(s)
- M Masetti
- Liver and Multivisceral Transplantation Center Division of Infectious Diseases, Azienda Ospedaliero-Universitaria di Modena-Policlinico, Modena, Italy.
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De Pietri L, Masetti M, Montalti R, Begliomini B, Reggiani A, Barbieri E, Biagioni E, Marietta M, Romano A, Pasetto A, Gerunda GE. Use of recombinant factor IX and thromboelastography in a patient with hemophilia B undergoing liver transplantation: a case report. Transplant Proc 2008; 40:2077-9. [PMID: 18675136 DOI: 10.1016/j.transproceed.2008.05.054] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Hemophilia B is a congenital recessive disorder caused by deficiency of coagulation factor IX (FIX). Surgical procedures can be performed in patients with hemophilia using high-purity and/or recombinant FIX, which has been shown to be safe and effective in surgical hemostasis. Liver transplantation is the only potentially curative treatment available for these patients, providing a long-term phenotypic cure for hemophilia. End-stage liver disease together with hemophilia exposes patients to greater risks of bleeding complications during the perioperative period with consequent difficulties in managing coagulopathy. The limited experiences reported by different investigators and the various strategies for clotting factor replacement make it difficult to define a single approach with respect to the optimal dose and method of administering FIX to achieve perioperative hemostasis. The limits of plasma-based coagulation tests--prothrombin time, activated partial thromboplastin time--have made thromboelastography a valid alternative in this kind of surgery. It has been demonstrated to be a useful tool for real-time analysis of clot formation using a whole-blood assay format. Further, it accurately illustrates the clinical effects of procoagulant or anticoagulant interventions. In this article, we have described the usefulness of thromboelastography to monitor the ability of high-purity FIX supplementation to restore a normal coagulation state and to guide the perioperative administration of blood products in a successful orthotopic liver transplantation in a hemophilic patient with deficiencies of factors IX and X, presenting with hepatitis C virus-related cirrhosis and hepatocellular carcinoma.
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Affiliation(s)
- L De Pietri
- Division of Anesthesiology, University of Modena and Reggio Emilia, Modena, Italy.
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Arzu GD, De Ruvo N, Montalti R, Masetti M, Begliomini B, Di Benedetto F, Rompianesi G, Di Sandro S, Smerieri N, D'Amico G, Vezzelli E, Iemmolo RM, Romano A, Ballarin R, Guerrini GP, De Blasiis MG, Spaggiari M, Gerunda GE. Temporary porto-caval shunt utility during orthotopic liver transplantation. Transplant Proc 2008; 40:1937-40. [PMID: 18675094 DOI: 10.1016/j.transproceed.2008.06.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION In liver transplantation (OLT) a porto-caval shunt is a well-defined technique practiced by many surgeons in several centers. METHODS We considered 186 cadaveric OLT patients who underwent a cavo-cavostomy-type reconstruction; they were divided into two groups: those in whom we performed a porto-caval shunt (group A) and those in whose we did not (group B). We evaluated several variables: warm and total ischemia time, intraoperative blood and fresh frozen plasma transfusions, crystalloid and colloid requirements, blood loss, operative duration, hemodynamic intraoperative changes and diuresis, length of hospital stay, and creatinine values at days 1 and 2, and at discharge day. RESULTS Total and warm ischemic time differed significantly between the two groups. Infusion of blood, fresh frozen plasma, colloid, and crystalloid did not significantly differ. Blood loss was lower, and intraoperative diuresis was not significantly increased in group A subjects. Postoperative hospitalizations were 16.5 and 17.8 days and operative times, 504 and 611 minutes in the two groups. Both cardiac index and ejection fraction values during the anhepatic phase were significantly greater among group A than group B patients. PAD at the two phases was greater in group B. The PAS was significantly different only at reperfusion time. Creatinine values were significantly different at discharge. Better survival was shown for group A patients over group B subjects. CONCLUSION The results presented herein confirmed that a porto-caval shunt during OLT was a safe, useful expedient contributing to an improved hemodynamic status and a better time distribution in the various phases of liver transplantation.
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Affiliation(s)
- G D Arzu
- Liver and Multivisceral Transplant Center, University of Modena, Modena, Italy
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5
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Lauro A, Diago Uso T, Quintini C, Di Benedetto F, Dazzi A, De Ruvo N, Masetti M, Cautero N, Risaliti A, Zanfi C, Ramacciato G, Begliomini B, Siniscalchi A, Miller CM, Pinna AD. Adult-to-adult living donor liver transplantation using left lobes: the importance of surgical modulations on portal graft inflow. Transplant Proc 2007; 39:1874-6. [PMID: 17692638 DOI: 10.1016/j.transproceed.2007.05.052] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Due to the shortage of available cadaveric organs, living donor liver transplantation (LDLT) has been recently applied extensively in adults. The use of the left lobe should be encouraged because of donor safety, but frequently the metabolic requirements of severely cirrhotic patients are great and subsequent graft dysfunction is encountered after transplantation. The importance of increased portal inflow to the graft in previously severely cirrhotic patients and other hemodynamic changes in LDLT using left lobes are still under debate, as are the surgical modulations to correct them. In this study, we have reported an initial series of adult-to-adult LDLT using left lobes, underlining the hemodynamic changes encountered during the transplant and the surgical modulations we applied to correct them. METHODS Eight adult recipients underwent left lobe liver transplantation from living donors. Portal vein pressure and central venous pressure were measured before and after surgical modulation. RESULTS We encountered four cases of small-for-size syndrome. Two patients were retransplanted; the other two died. Seventy-five percent of our recipients survived and 50% did not require further surgery. CONCLUSION Surgical portal inflow modulation should be considered in cases of left lobe liver transplantation between adults.
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Affiliation(s)
- A Lauro
- Liver and Multiorgan Transplant Unit, Policlinico Sant'Orsola-Malpighi, University of Bologna, Bologna, Italy.
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Lauro A, Dazzi A, Ercolani G, Cescon M, D'Errico A, Di Simone M, Grazi GL, Vivarelli M, Varotti G, De Ruvo N, Masetti M, Cautero N, Di Benedetto F, Siniscalchi A, Begliomini B, Lazzarotto T, Faenza S, Pironi L, Pinna AD. Results of intestinal and multivisceral transplantation in adult patients: Italian experience. Transplant Proc 2006; 38:1696-8. [PMID: 16908252 DOI: 10.1016/j.transproceed.2006.05.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE We report our experience with intestinal and multivisceral transplantation in Italy. METHODS We performed 23 adult isolated intestinal transplants and seven multivisceral ones, three with liver, between December 2000 and June 2005. Indications for transplantation were loss of venous access (n = 14), recurrent sepsis (n = 10), and electrolyte-fluid imbalance (n = 6), 14 of whom also presented with total parenteral nutrition (TPN)-related liver dysfunction. Immunosuppression was based on induction agents like daclizumab (followed by tacrolimus and steroids) in the first period; alemtuzumab or thymoglobulin (with tacrolimus) in a second period after 2002. RESULTS The mean follow-up was 742 +/- 550 days. Three-year patient actuarial survival rate was 88% for intestinal transplants and 42% for multivisceral (P = .015). Three-year graft actuarial survival rate was 73% for intestinal patients and 42.8% for multivisceral (P = .1). Graft loss was mainly due to rejection (57%). Complications were mainly represented by bacterial infections (92% of patients), relaparotomies (82%), and rejections (72%). Full bowel function without any parenteral nutrition or intravenous fluid support was achieved in 60% of recipients with functioning bowel including 95% on a regular diet. One patient underwent abdominal wall transplantation as well. DISCUSSION AND CONCLUSION Intestinal transplantation has achieved high rates of patient and graft survival with even longer follow-up. Early referral of patients, especially in cases of TPN-liver disease, is mandatory to obtain good outcomes and avoid high mortality rates on the transplant waiting list. Immunosuppressive management remains the key factor to increase the success rate.
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Affiliation(s)
- A Lauro
- UO Chirurgia dei Trapianti di Fegato e Multiorgano, University of Bologna, Policlinico S. Orsola-Malpighi, PAD 25, Via Massarenti 9, 40138 Bologna, Italy.
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Siniscalchi A, Spedicato S, Lauro A, Pinna AD, Cucchetti A, Dazzi A, Piraccini E, Begliomini B, Braglia V, Serri T, Faenza S. Intraoperative coagulation evaluation of ischemia-reperfusion injury in small bowel transplantation: a way to explore. Transplant Proc 2006; 38:820-2. [PMID: 16647482 DOI: 10.1016/j.transproceed.2006.01.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND AND AIM OF STUDY The success of intestinal transplantation is affected by the extreme susceptibility of the small bowel to ischemia-reperfusion (I/R) injury. Platelet aggregation decreases after reperfusion in small intestinal ischemia and liver transplantation. Thromboelastography (TEG) is a coagulation test performed whole on blood. The aims of this study were to assess coagulation derangements during bowel transplantation to define appropriate modalities of intraoperative coagulation monitoring. A secondary endpoint was to determine whether measurements of coagulation derangements were useful to estimate small intestinal I/R injury. MATERIALS AND METHODS We recruited 19 patients who had undergone elective small bowel transplantation for primary short-gut syndrome. We divided our patients into two groups depending on their reperfusion injury as evaluated with a biopsy after reperfusion: group A composed of eight patients who had a reperfusion injury: group B composed of 11 patients who did not experience this problem. We measured five thromboelastogram indicators (r, k, angle, MA, CL30) at defined intervals: dissection phase (T1), vascular anastomoses phase (T2) as well as 30 minutes (T3) and 120 minutes (T4) after reperfusion during the intestinal reconstruction phase. RESULTS We did not observe any significant difference between intraoperative blood loss, core temperature, or volume of fluid fresh frozen plasma, or platelet administration. Angle and MA were decreased significantly among patients with reperfusion injury. DISCUSSION Patients showed a hypocoagulation pattern during all the manipulations. This derangement did not depend on the ischemia time. In patients with I/R injury the angle and MA did not change during ischemia, but did change significantly upon reperfusion. Several mechanisms may cause coagulation derangements. During the ischemic period, there may be damage to the vascular bed of the ischemic organ. When arterial blood passes through the damaged vascular bed after reperfusion, platelet activation occurs to varying degrees, resulting in reduced platelet function. CONCLUSION Further studies are needed to confirm this preliminary work, which was limited by the low number of patients, in order to elucidate relevant mechanisms and develop predictive algorithms.
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Affiliation(s)
- A Siniscalchi
- Department of Anesthesiology, Liver and Multiorgan Transplant Unit, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy.
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Busani S, Rinaldi L, Begliomini B, Pasetto A, Girardis M. Thymoglobulin-induced severe cardiovascular reaction and acute renal failure in a patient scheduled for orthotopic liver transplantation. Minerva Anestesiol 2006; 72:243-8. [PMID: 16570036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Antithymocyte globulin (ATG) has been shown to be effective as a pretreatment immunosuppressive agent in liver transplantation because of the ability to wean tacrolimus monotherapy after 4 months in pretreated recipients. However, the use of ATG can be complicated by serious side effects. Reported side effects include severe cardiopulmonary reactions, adult respiratory distress syndrome and hematological disorders. We report a case of a patient with a medical history of cirrhosis scheduled for orthotopic liver transplantation that, during the operation, showed swelling, hyperthermia, tachycardia and hypotension after the administration of ATG. Acute renal failure (ARF) was another serious side effect that our patient developed during ICU stay; we ascribed the occurrence of ARF to the serum sickness disease triggered by the ATG administration. Only one case has been reported of ARF after ATG-therapy before our experience. Therefore, severe hyperthermia and signs of cardiovascular dysfunction early after the beginning of ATG administration should be carefully evaluated and may need to consider the immediate ATG therapy withdrawal to prevent ARF.
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Affiliation(s)
- S Busani
- Department of Anesthesia and Intensive Care, University of Modena and Reggio Emilia, Polyclinic of Modena, Modena, Italy.
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Lauro A, Di Benedetto F, Masetti M, Cautero N, Ercolani G, Vivarelli M, De Ruvo N, Cescon M, Varotti G, Dazzi A, Siniscalchi A, Begliomini B, Pironi L, Di Simone M, D'Errico A, Ramacciato G, Grazi G, Pinna AD. Twenty-Seven Consecutive Intestinal and Multivisceral Transplants in Adult Patients: A 4-Year Clinical Experience. Transplant Proc 2005; 37:2679-81. [PMID: 16182782 DOI: 10.1016/j.transproceed.2005.06.071] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Adult isolated intestinal and multivisceral transplantation is gaining acceptance as the standard treatment for patients with intestinal failure with life-threatening parenteral nutrition-related complications. We report our 4-year experience with intestinal and multivisceral transplantation. We performed 20 isolated small bowel and seven multivisceral ones, including three with liver. The underlying diseases were mainly short bowel syndrome due to intestinal infarction, chronic intestinal pseudo-obstruction, and Gardner syndrome. Indications for transplant were loss of central venous access in 14 patients, recurrent sepsis in eight patients, and major electrolyte and fluid imbalance in five patients. One-year patient actuarial survival rate was 94% for isolated intestinal transplants and 42% for multivisceral recipients (P = .003), while 1-year graft actuarial survival rate was 88.4% for isolated small bowel patients and 42.8% for multivisceral ones (P = .01). The death rate was 18.5%. Our graftectomy rate was 14.8%. Our immunosuppressive protocols were based on induction agents such as alemtuzumab, daclizumab, and antithymocyte globulins. The majority of our complications were bacterial infections, followed by rejections and relaparotomies; most rejection episodes were treated with steroid boluses and tapering. We believe that our results were due to optimal candidate and donor selection, short ischemia time, and use of induction therapy. Multivisceral transplantation is a more complex procedure with less frequent clinical indications than isolated small bowel transplant, but our data concerning multivisceral transplants include only a small number of patients and require further evaluation.
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Affiliation(s)
- A Lauro
- UO Chirurgia dei Trapianti di Fegato e Multiorgano, University of Bologna Policlinico S. Orsola-Malpighi, Bologna, Italy.
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Lauro A, Diago Usò T, Masetti M, Di Benedetto F, Cautero N, De Ruvo N, Dazzi A, Quintini C, Begliomini B, Siniscalchi A, Ramacciato G, Risaliti A, Miller CM, Pinna AD. Liver Transplantation for Familial Amyloid Polyneuropathy Non-VAL30MET Variants: Are Cardiac Complications Influenced by Prophylactic Pacing and Immunosuppressive Weaning? Transplant Proc 2005; 37:2214-20. [PMID: 15964382 DOI: 10.1016/j.transproceed.2005.03.065] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2005] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cardiac complications represent a cause of morbidity and mortality after liver transplantation among patients with familial amyloid polyneuropathy (FAP), especially for the non-VAL30MET variant types. METHODS We retrospectively evaluated 11 recipients from a nonendemic area including 90.9% affected by FAP variants. Preoperative cardiovascular symptoms were present in 81% of patients. An intraoperative pacemaker was placed prophylactically in 90.9% of all recipients. Since tacrolimus has been reported in the international literature to display cardiac toxicity, we evaluated the influence of intraoperative prophylactic pacing and rapid postoperative weaning from tacrolimus, mainly allowed by thymoglobulin on the occurrence of posttransplantation cardiac complications. RESULTS One patient received a combined heart-liver transplant, another, living donor liver transplantation. We did not observe any significant intraoperative cardiac complications. Postoperatively, the pacemaker was removed from all patients but 1. Five patients received tacrolimus and steroids; a subsequent, second group of 6 patients (54.5%) was treated with thymoglobulin followed by tacrolimus. At discharge the mean tacrolimus level was 10.6 ng/mL, whereas after 1 month it was 7.5 ng/mL. We observed a case of acute cellular rejection before discharge, which was successfully treated with intravenous steroids and OKT3. After a mean follow-up of 17.4 months (range, 1-31), 2 patients had died (18.1%): 1 due to sepsis and another, to MI. Two recipients experienced cardiac complications (18.1%), namely, the patient who died due to an myocardial infarction and a second one with a tachyarrhythmia, which was treated successfully with beta-blockers and amiodarone. CONCLUSION Prophylactic pacing and rapid weaning from immunosuppression are still associated with a significant rate of postoperative cardiac complications.
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Affiliation(s)
- A Lauro
- UO Chirurgia dei Trapianti di Fegato e Multiorgano, PAD 25-Policlinico S. Orsola-Malpighi, Universitá di Bologna, Via Massarenti 9, 40138 Bologna, Italy.
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Di Benedetto F, Lauro A, Masetti M, Cautero N, Quintini C, Dazzi A, De Ruvo N, Uso TD, Begliomini B, Siniscalchi A, Bagni A, Codeluppi M, Ramacciato G, Villa E, Pinna AD. Outcomes after adult isolated small bowel transplantation: experience from a single European centre. Dig Liver Dis 2005; 37:240-6. [PMID: 15788207 DOI: 10.1016/j.dld.2004.10.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2004] [Accepted: 10/05/2004] [Indexed: 12/11/2022]
Abstract
BACKGROUND Adult isolated small bowel transplantation is considered the standard treatment for patients with life-threatening parenteral nutrition-related complications. Here, we report a 3-year experience in a single European centre between December 2000 and December 2003. AIMS To evaluate and discuss pre-transplant and post-transplant factors that influenced survival rates in our series. PATIENTS Fourteen patients, with a mean parenteral nutrition course of 27 months, were transplanted. In eight cases they had not experienced any major complication from parenteral nutrition. METHODS We described pre-transplant evaluation and inclusion criteria, surgical technique and clinical management after transplant. Immunosuppressive therapy was based on induction drugs and Tacrolimus. We reported survival rates, major complications and rejection events. RESULTS One-year actuarial survival rate was of 92.3% with a mean 21-month follow-up (range 3-36 months). We had no intraoperative deaths. One patient (7.2%) died of sepsis following cytomegalovirus enteritis. One patient underwent graftectomy (7.2%) for intractable severe acute rejection. One-year actuarial graft survival rate of 85.1%. One patient (7.2%) affected by post-transplant lymphoproliferative disease is alive and disease-free after 8 months. CONCLUSION We believe candidate selection, induction therapy, donor selection and short ischemia time play an important role in survival after small bowel transplantation.
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Affiliation(s)
- F Di Benedetto
- Liver and Multivisceral Transplant Centre, University of Modena and Reggio Emilia, Policlinico of Modena-via del Pozzo 71, 41100 Modena, Italy.
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12
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Di Benedetto F, Lauro A, Masetti M, Cautero N, De Ruvo N, Quintini C, Sassi S, Di Francesco F, Diago Usò T, Romano A, Dazzi A, Molteni G, Begliomini B, Siniscalchi A, De Pietri L, Bagni A, Merighi A, Codeluppi M, Girardis M, Ramacciato G, Pinna AD. [Outcome of isolated small bowel transplantation in adults: experience from a single Italian center]. MINERVA CHIR 2005; 60:1-9. [PMID: 15902047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
AIM Isolated small bowel transplantation is becoming the treatment of choice for adult patients with serious parenteral nutrition (PN) related complications: we report our three-year experience (December 2000-December 2003) from a single Italian center (Modena-Italy), with one of the larger European series. METHODS We transplanted 14 patients, with a previous mean PN course of 27 months and a mean 21-month post-transplantation follow-up (range 3-36 months), obtaining a one-year actuarial survival rate of 92.3% with no intraoperative deaths. RESULTS We lost 1 patient (7.2%), died for post-transplantation overwhelming sepsis following Cytomegalovirus (CMV) enteritis. Thirteen patients are alive, with one-year actuarial graft survival rate of 85.1%: 1 patient underwent graft removal (7.2%) for intractable severe acute rejection. Our immunosuppressive regimen was based on tacrolimus and 3 induction protocols: daclizumab (8 patients) with steroids, alemtuzumab (4 patients) and thymoglobulin (2 patients) without steroids. In 9 cases, we added sirolimus. Nine recipients experienced 22 episodes of acute cellular rejection (ACR), treated successfully in all cases but one. One patient (7.2%) was treated successfully for Post Transplant Lymphoproliferative Disease (PTLD) and is disease-free after 8 months. CONCLUSIONS Small bowel transplantation can achieve optimal results depending on appropriate immunosuppressive management and candidate selection, added to shorter ischemia time and careful donor and graft selection.
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Affiliation(s)
- F Di Benedetto
- Centro Trapianti di Fegato e Multiviscerale, Policlinico di Modena, Università degli Studi di Modena e Reggio Emilia, Italy.
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13
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Masetti M, Cautero N, Lauro A, Di Benedetto F, Begliomini B, Siniscalchi A, Pironi L, Miglioli M, Bagni A, Pinna AD. Three-year experience in clinical intestinal transplantation. Transplant Proc 2004; 36:309-11. [PMID: 15050141 DOI: 10.1016/j.transproceed.2004.01.106] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the outcome of 19 patients who underwent intestinal transplantation (ITx) for intestinal failure. METHODS The 19 patients who underwent primary ITx between December 2000 and May 2003 were prescribed three different immunosuppressive protocols that included daclizumab, alemtuzumab, and antithymocyte globulin induction, respectively. A mucosal surveillance protocol for early detection of rejection consisted of zoom video endoscopy and serial biopsies associated with orthogonal polarization spectral imaging. Retrospective review of the clinical records was performed to assess the impact of new modalities of immunosuppression and intestinal mucosal monitoring on patient outcomes. RESULTS All patients were adults (mean age 35.8 years). Etiology of intestinal failure included chronic intestinal pseudo-obstruction (n = 6), intestinal angiomatosis (n = 1), Gardner syndrome (n = 2), intestinal infarction (n = 8), radiation enteritis (n = 1), and intestinal atresia (n = 1). All patients experienced complications from total parenteral nutrition (TPN). Thirteen patients (68.4%) received isolated small bowel, whereas six (31.6%) received multivisceral grafts with or without the liver. Thirteen of 19 patients experienced at least one episode of rejection (68.4%). Most ACR episodes were treated with steroid boluses and resolved completely within 5 days. The overall 1-year patient survival was 82%. All living patients are in good health with functioning grafts having been weaned off TPN after a mean of 23.7 days post-ITx. DISCUSSION Advances in immunosuppressive therapy with early detection and prompt treatment of rejection episodes make ITx a valuable treatment option for patients with intestinal failure and TPN-related life-threatening complications.
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Affiliation(s)
- M Masetti
- Liver and Multivisceral Transplant Center, Modena, Italy.
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14
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Siniscalchi A, Begliomini B, Matteo G, De Pietri L, Pasetto A. Intraoperative effects of combined versus general anesthesia during major liver surgery. Minerva Anestesiol 2003; 69:885-95. [PMID: 14743120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
AIM The study compares the intraoperative effects of combined versus general anesthesia during major liver surgery. METHODS In this prospective randomized study, 70 patients were divided into 2 group of 35 subjects. Group A received general anesthesia (thiopentone, fentanyl, vecuronium, sevoflurane in a closed circuit) 15 minutes after placement of an epidural catheter (D9-D10) and induction of epidural anesthesia (6 ml 2% naropine). Continuous epidural infusion was initiated before surgical incision and continued with 0.2% naropine (7 ml/h) until the end of the operation. Group B received combined intraoperative anesthesia wit fentanyl doses according to hemodynamic parameters and 0.1 mg/kg morphine 30-4 minutes before cutaneous suture. Hemodynamic values were measured at base line (T0), and then at 15, 30, 60, 120 and 180 minutes after induction of general anesthesia (T1, T2, T3, T4 and T5, respectively). On recovery, patients were assessed for pain at rest and on movement reported on a visual analog scale; degree of motor blockade according to the Bromage scale; appearance of side effects; use af analgesic. RESULTS A statistically significant decrease in the mean arterial blood pressure (ABP) and heart rate (HR) was noted within each group at 15 minutes after induction of general anesthesia. Significant differences in ABP were found between the 2 groups at T1 to T5, whereas HR values were substantially similar. The mean intraoperative use of fentanyl was significantly higher in Group B than in Group A, as was that of vecuronium. Pain intensity on recovery in patients who received epidural anesthesia was lower both at rest and on movement; only the patients in Group B required additional analgesics. No motor blockade was observed in either group. Nausea and vomiting were more frequent in Group B; hypotension was more frequent in Group A. CONCLUSION The study confirms the safety of locoregional anesthesia in liver surgery, with good hemodynamic stability and absence of major side effects. The lower intraoperative use of opioids and muscle relaxants in patients who received epidural anesthesia confirms the neurovegetative protection this method provides. The data support the hypothesis that greater intraoperative use of opioids may be responsible for the higher incidence of side effects. Therefore, the intraoperative use of combined low-concentration anesthetic agents alone appears to offer a reasonable treatment option that provides adequate pain control at recovery from general anesthesia, with only minor side effects typically associated with analgesic (motor blockade) and opioids (nausea and vomiting). Given the complications associated with the technique, it should be performed by an expert anesthetist.
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Affiliation(s)
- A Siniscalchi
- Anesthesia and Resuscitation Specialty School, Department of Emergency and Surgical Sciences, University of Modena and Reggio Emilio, Modena, Italy
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15
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Ramacciato G, Mercantini P, Corigliano N, Cautero N, Masetti M, Di Benedetto F, Quintini C, Balducci G, Siniscalchi A, Begliomini B, Ziparo V, Pinna A. Hepatic resections for hepatocellular carcinoma (HCC): short and long-term results on 106 cirrhotic patients. J Exp Clin Cancer Res 2003; 22:233-41. [PMID: 16767938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
To evaluate the short and long term outcome of liver resections for hepatocellular carcinoma in cirrhotic patients. A retrospective analysis was performed on 106 consecutive cirrhotic patients with hepatocellular carcinoma resected between June 1974 and September 2002 at the Department of Surgery "Pietro Valdoni" - University of Rome "La Sapienza" and at the Liver and Multivisceral Transplant Unit of the University of Modena. Univariate and multivariate analyses were performed on several clinicopathological variables to analyze factors affecting the long-term outcome and intrahepatic recurrence. Overall mortality and morbidity were 10.7% and 26% respectively. These rates significantly decreased in the last years: from 1997 to 2002 no hospital mortality has been recorded. After a median follow-up of 19 months (interquartile range: 10-36), tumour recurrence appeared in 25 patients (23,5%). The 1-, 3-, and 5-year overall survival rates were 86,6%, 70,3%, and 60,6%, respectively. The 1-, 3-, and 5-year disease-free survival rates were 86,3%, 58,1%, and 40,7%. On univariate analysis, viral ethiology of cirrhosis (p=0.03), presence of multiple nodules (p=0.02) and vascular invasion (p=0.05) were found to be related to a worse long-term survival. At the multivariate analysis only the viral ethiology of cirrhosis and the presence of multiple nodules were confirmed as indipendent prognostic factors. Early results after hepatic resection for HCC can be improved by using a limited surgical approach. The viral ethiology of cirrhosis, the presence of multiple nodules and vascular invasion negatively affected recurrence rate and long-term survival.
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Affiliation(s)
- G Ramacciato
- University of Rome La Sapienza, II Faculty of Medicine and Surgery, Azienda Ospedaliera Sant'Andrea, UOC Chirurgia A, Italy.
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16
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Pinna A, Masetti M, Miller C, Dazzi A, Begliomini B, Siniscalchi A, Cautero N, Di Benedetto F, Lauro A, Girardis M, Villa E, Ramacciato G. [Living donor liver transplantation, adult to adult]. MINERVA CHIR 2003; 58:657-73. [PMID: 14603146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
AIM Since living donor liver transplantation (LDLT) can offer a viable response to the lack of transplantable cadaveric organs, our center instituted an LDLT program in 2001. METHODS The authors report their experience with the first 35 LDLT procedures successfully completed at the Liver and Multiorgan Transplant Center of the University of Modena between 9 May 2001 and 21 May 2003. The case series comprised 35 patients, 7 of which received a left-half liver and 1 a left lobe. RESULTS The global survival rate was 77.2% (27 out of 35 patients), with a mean follow-up period of 295 days; the survival rate at 1 year was 81%. In 4 cases (11%) retransplantation was performed. The donor demographics are described; all donors returned to their normal activities before transplantation, after a mean follow-up period of 373 days. No intraoperative complications were experienced by the donors, whereas during the postoperative period, 2 donors (5.7%) developed major complications (1 biliary fistula on the cut surface, 1 stenosis of the main bile duct). CONCLUSION Our study shows that LDLT can be safely completed in the donor, with good results achieved in the recipient as well. Underlying these results is the accurate pretransplant assessment that continued into the operation itself. Even more important was the demonstrated ability and experience of the surgical team to attain results in the donor which we believe are necessary for carrying forth a LDLT program.
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Affiliation(s)
- A Pinna
- Centro Trapianti di Fegato e Multiviscerale, Università degli Studi di Modena e Reggio Emilia, Modena e Reggio Emilia, Italy.
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17
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Siniscalchi A, Begliomini B, De Pietri L, Ivagnes Petracca S, Braglia V, Girardis M, Pasetto A, Masetti M, Cautero N, Jovine E, Pinna AD. Pain management after small bowel/multivisceral transplantation. Transplant Proc 2002; 34:969-70. [PMID: 12034265 DOI: 10.1016/s0041-1345(02)02721-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- A Siniscalchi
- Anesthesiology and Critical Care Unit, University of Modena, Modena, Italy.
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18
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Masetti M, Jovine E, Begliomini B, Cautero N, Di Benedetto F, Gelmini R, Villa E, Merighi A, Bagni A, Bezer L, Pinna AD. Intestinal/multivisceral transplantation: University of Modena experience. Transplant Proc 2002; 34:863-4. [PMID: 12034210 DOI: 10.1016/s0041-1345(02)02736-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- M Masetti
- Liver and Multivisceral Transplant Center, University of Modena and Reggio Emilia, Modena, Italy
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19
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Jovine E, Masetti M, Cautero N, Di Benedetto F, Gelmini R, Sassi S, Quintini C, Andreotti A, Begliomini B, Siniscalchi A, Pinna AD. Modified multivisceral transplantation without a liver graft for Gardner/Desmoid syndrome and chronic intestinal pseudo-obstruction. Transplant Proc 2002; 34:911-2. [PMID: 12034234 DOI: 10.1016/s0041-1345(02)02665-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- E Jovine
- Liver and Multivisceral Transplant Center, Modena, Italy.
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20
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Cautero N, Gelmini R, Villa E, Bagni A, Merighi A, Masetti M, Di Benedetto F, Di Francesco F, Bezer L, Begliomini B, Jovine E, Pinna AD. Orthogonal polarization spectral imaging: a new tool in morphologic surveillance in intestinal transplant recipients. Transplant Proc 2002; 34:922-3. [PMID: 12034240 DOI: 10.1016/s0041-1345(02)02671-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- N Cautero
- Liver and Multivisceral Transplant Center, University of Modena and Reggio Emilia, Italy, Modena, Italy
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21
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Molenaar IQ, Legnani C, Groenland TH, Palareti G, Begliomini B, Terpstra OT, Porte RJ. Aprotinin in orthotopic liver transplantation: evidence for a prohemostatic, but not a prothrombotic, effect. Liver Transpl 2001; 7:896-903. [PMID: 11679989 DOI: 10.1053/jlts.2001.27854] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Aprotinin reduces blood transfusion requirements in orthotopic liver transplantation (OLT). Concern has been voiced about the potential risk for thrombotic complications when aprotinin is used. The aim of this study is to evaluate the effects of aprotinin on the two components of the hemostatic system (coagulation and fibrinolysis) in patients undergoing OLT. As part of a larger, randomized, double-blind, placebo-controlled study, we compared coagulation (fibrinogen level, activated partial thromboplastin time [aPTT], prothrombin time, and platelet count) and fibrinolytic variables (tissue-type plasminogen activator [tPA] antigen and activity, plasminogen activator inhibitor activity, and D-dimer), as well as thromboelastography (reaction time [r], clot formation time, and maximum amplitude) in 27 patients administered either high-dose aprotinin (2 x 10(6) kallikrein inhibitor units [KIU] at induction, continuous infusion of 1 x 10(6) KIU/h, and 1 x 10(6) KIU before reperfusion; n = 10), regular-dose aprotinin (2 x 10(6) KIU at induction and continuous infusion of 0.5 x 10(6) KIU/h; n = 8), or placebo (n = 9) during OLT. Blood samples were drawn at seven standardized intraoperative times. Baseline characteristics were similar for the three groups. During the anhepatic and postreperfusion periods, fibrinolytic activity (plasma D-dimer and tPA antigen levels) was significantly lower in aprotinin-treated patients compared with the placebo group. Interestingly, coagulation times (aPTT and r) were significantly more prolonged in aprotinin-treated patients than the placebo group. No difference was seen in the incidence of perioperative thrombotic complications in the entire study population (n = 137). Aprotinin has an anticoagulant rather than a procoagulant effect. Its blood-sparing (prohemostatic) effect appears to be the overall result of a strong antifibrinolytic and a weaker anticoagulant effect. These findings argue against a prothrombotic effect of aprotinin in patients undergoing OLT.
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Affiliation(s)
- I Q Molenaar
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
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22
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Molenaar IQ, Begliomini B, Martinelli G, Putter H, Terpstra OT, Porte RJ. Reduced need for vasopressors in patients receiving aprotinin during orthotopic liver transplantation. Anesthesiology 2001; 94:433-8. [PMID: 11374602 DOI: 10.1097/00000542-200103000-00012] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Graft reperfusion in orthotopic liver transplantation is often associated with significant hemodynamic changes, including decreased systemic vascular resistance and arterial blood pressure. Vasopressive drugs are often required to maintain adequate perfusion pressure during the early postreperfusion period. The exact mechanism of this postreperfusion syndrome is unknown, but release of bradykinin, a potent vasodilatator, via the kallikrein system may play a role. Aprotinin is a broad-spectrum inhibitor of serine proteases such as kallikrein and therefore may ameliorate the postreperfusion syndrome and reduce the need for vasopressors. METHODS In a randomized, double-blind study, the authors compared hemodynamic variables (systemic vascular resistance, cardiac index, arterial blood pressure, mean pulmonary artery pressure, central venous pressure) and the requirement of epinephrine during transplantation in 67 patients who received either high-dose aprotinin (2 x 10(6) kallikrein inhibitor units [KIU] at induction, continuous infusion of 1 x 10(6) KIU/h, 1 x 10(6) KIU before reperfusion; n = 24), regular-dose aprotinin (2 x 10(6) KIU at induction, continuous infusion of 0.5 x 10(6) KIU/h; n = 21), or placebo (n = 22). RESULTS Baseline characteristics were similar for all three groups. Erythrocyte transfusion requirement was significantly higher in the placebo group compared with both aprotinin-treated groups. No major differences in hemodynamic variables were found between the three groups. The total amount of epinephrine (median, range) used during transplantation, however, was significantly lower in patients who received aprotinin (high dose, 20, 0-170 microg; regular dose, 30, 0-140 microg), compared with patients who received placebo (70, 0-2,970 microg; P = 0.0017). This difference was largely attributable to differences in the early postreperfusion period. CONCLUSIONS Prophylactic use of aprotinin ameliorates the postreperfusion syndrome in orthotopic liver transplantation, as reflected by a significant reduction in vasopressor requirements.
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Affiliation(s)
- I Q Molenaar
- Department of Surgery, Leiden University Medical Center, The Netherlands
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23
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Molenaar IQ, Veldman M, Begliomini B, Groenland HN, Januszkiewicz A, Lindgren L, Metselaar HJ, Terpstra OT, Porte RJ. Improved early graft survival in patients receiving aprotinin during orthotopic liver transplantation. Transplant Proc 2001; 33:1345-6. [PMID: 11267320 DOI: 10.1016/s0041-1345(00)02503-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- I Q Molenaar
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
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24
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Abstract
BACKGROUND In the European Multicenter Study on the Use of Aprotinin in Liver Transplantation (EMSALT), a randomized, double-blind, placebo-controlled, prospective study, we demonstrated that aprotinin significantly reduces intraoperative blood loss during orthotopic liver transplantation (OLT). Aprotinin is metabolized in the kidney and potentially nephrotoxic at high concentrations. Renal insufficiency is a common and serious complication after OLT. It is unknown whether aprotinin increases the risk of renal failure after OLT. METHODS We analyzed intraoperative urine output, need for postoperative dialysis, perioperative serum creatinine levels, and creatinine clearance in 93 patients enrolled in EMSALT, receiving a high dose of aprotinin, a regular dose, or placebo. RESULTS Peak increase in serum creatinine exceeding 0.5 mg/dl during one of the postoperative days occurred in 11 (35%) patients in the placebo group, in 11 (34%) patients in the high-dose group, but only in 1 (3%) patient in the regular-dose group (P=0.007). Furthermore, a perioperative decrease in creatinine clearance was seen in the placebo group (-23.9+/-10.1 ml/min) but not in both high-dose (-1.6+/-13.3 ml/min) and regular-dose (9.7+/-10.3 ml/min) groups (P<0.02 comparing regular-dose and placebo group). CONCLUSIONS Despite its potential nephrotoxicity, the use of aprotinin for reducing blood loss during OLT does not lead to a higher incidence of postoperative renal insufficiency. In combination with the observed reduction in blood loss, these findings support the prophylactic use of regular-dose aprotinin during OLT.
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Affiliation(s)
- I Q Molenaar
- Department of Surgery, Leiden University Medical Center, The Netherlands
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25
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Porte RJ, Molenaar IQ, Begliomini B, Groenland TH, Januszkiewicz A, Lindgren L, Palareti G, Hermans J, Terpstra OT. Aprotinin and transfusion requirements in orthotopic liver transplantation: a multicentre randomised double-blind study. EMSALT Study Group. Lancet 2000; 355:1303-9. [PMID: 10776742 DOI: 10.1016/s0140-6736(00)02111-5] [Citation(s) in RCA: 247] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Intraoperative hyperfibrinolysis contributes to bleeding during adult orthotopic liver transplantation. We aimed to find out whether aprotinin, a potent antifibrinolytic agent, reduces blood loss and transfusion requirements. METHODS We did a randomised, double-blind, placebo-controlled trial in which six liver-transplant centres participated. Patients undergoing primary liver transplantation were randomly assigned intraoperative high-dose aprotinin, regular-dose aprotinin, or placebo. Primary endpoints were intraoperative blood loss and transfusion requirements. Secondary endpoints were perioperative fluid requirements, postoperative blood transfusions, complications, and mortality. FINDINGS 137 patients received high-dose aprotinin (n=46), regular-dose aprotinin (n=43), or placebo (n=48). Intraoperative blood loss was significantly lower in the aprotinin-treated patients, with a reduction of 60% in the high-dose group and 44% in the regular-dose group, compared with the placebo group (p=0.03). Total amount of red blood cell (homologous and autologous) transfusion requirements was 37% lower in the high-dose group and 20% lower in the regular-dose group, than in the placebo group (p=0.02). Thromboembolic events occurred in two patients in the high-dose group, none in the regular-dose group, and in two patients in the placebo group (p=0.39). Mortality at 30 days did not differ between the three groups (6.5%, 4.7%, and 8.3%; p=0.79). INTERPRETATION Intraoperative use of aprotinin in adult patients undergoing orthotopic liver transplantation significantly reduces blood-transfusion requirements and should be routinely used in patients without contraindications.
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Affiliation(s)
- R J Porte
- Department of Surgery, Leiden University Medical Centre, The Netherlands.
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26
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Bandini G, Stanzani M, Bonifazi F, Begliomini B, Fruet F. Allergy to latex. Lancet 2000; 355:850. [PMID: 10711961 DOI: 10.1016/s0140-6736(05)72470-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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27
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Jovine E, Mazziotti A, Grazi GL, Ercolani G, Masetti M, Morganti M, Pierangeli F, Begliomini B, Mazzetti PG, Rossi R, Paladini R, Cavallari A. Piggy-back versus conventional technique in liver transplantation: report of a randomized trial. Transpl Int 1997. [PMID: 9089994 DOI: 10.1111/j.1432-2277.1997.tb00550.x] [Citation(s) in RCA: 109] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Liver transplantation with preservation of the recipient vena cava (the "piggy-back" technique) has been proposed as an alternative to the traditional method. We performed a randomized study on 39 cirrhotic patients, 20 who underwent the piggy-back technique (group 1) and 19 the traditional method using venovenous bypass (group 2) to evaluate the feasibility and true advantages of the piggy-back technique compared to the traditional method. Two patients were switched to the conventional technique due to the presence of a caudate lobe embracing the vena cava in one patient and a caval lesion in the other. Statistically significant differences between the two groups were only found for the warm ischemia time (48.5 +/- 13 min for piggy-back vs 60 +/- 12 min for the conventional method) and for renal failure (zero cases in group 1 vs four cases in group 2). We therefore believe that liver transplantation with the piggy-back technique can easily be performed in almost all cases, and that only a few, specific situations, such as a very enlarged caudate lobe, do not justify its routine use.
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Affiliation(s)
- E Jovine
- Second Department of Surgery, University of Bologna, Policlinico S. Orsola, Italy
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28
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Abstract
Cervicothoracoabdominal and cervicoabdominal approach are routinely adopted for total or subtotal esophagectomy. We propose a modification of the Nanson's patient position to optimize sequential or simultaneous left cervicotomy, laparotomy, and eventual right thoracotomy with one or two surgical teams. This technique permits better control of the operative field for each phase of the procedure with coordinated operating of two surgical teams on the neck, abdomen, and chest.
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Affiliation(s)
- S Mattioli
- Department of Surgery, Intensive Care, and Organ Transplantation, University of Bologna, Italy
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29
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Jovine E, Mazziotti A, Grazi GL, Ercolani G, Masetti M, Morganti M, Pierangeli F, Begliomini B, Mazzetti PG, Rossi R, Paladini R, Cavallari A. Piggy-back versus conventional technique in liver transplantation: report of a randomized trial. Transpl Int 1997; 10:109-12. [PMID: 9089994 DOI: 10.1007/pl00003824] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Liver transplantation with preservation of the recipient vena cava (the "piggy-back" technique) has been proposed as an alternative to the traditional method. We performed a randomized study on 39 cirrhotic patients, 20 who underwent the piggy-back technique (group 1) and 19 the traditional method using venovenous bypass (group 2) to evaluate the feasibility and true advantages of the piggy-back technique compared to the traditional method. Two patients were switched to the conventional technique due to the presence of a caudate lobe embracing the vena cava in one patient and a caval lesion in the other. Statistically significant differences between the two groups were only found for the warm ischemia time (48.5 +/- 13 min for piggy-back vs 60 +/- 12 min for the conventional method) and for renal failure (zero cases in group 1 vs four cases in group 2). We therefore believe that liver transplantation with the piggy-back technique can easily be performed in almost all cases, and that only a few, specific situations, such as a very enlarged caudate lobe, do not justify its routine use.
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Affiliation(s)
- E Jovine
- Second Department of Surgery, University of Bologna, Policlinico S. Orsola, Italy
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30
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Melloni C, Faenza S, Melotti R, Paladini R, Fusari M, Begliomini B, Mastrorilli M, Cipolla d'Abruzzo G, D'Alessandro R, Schiavina M. [Myasthenia and muscle relaxants]. Minerva Anestesiol 1993; 59:217-21. [PMID: 8102793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Eighteen myasthenic patients have been operated on under general anaesthesia; 14 subjected to thymectomy and 2 to emergency procedures (caesarean section and laparotomy because of intestinal obstruction). Atracurium (0.3 mg/kg) and vecuronium (0.06 mg/kg) exhibited a long duration of action only in the two cases affected by the more severe signs and symptoms of the disease.
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Affiliation(s)
- C Melloni
- Istituto di Anestesia e Rianimazione, Università degli Studi di Bologna
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31
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Abstract
Right ventricular (RV) function was assessed in 20 patients undergoing orthotopic liver transplantation to determine its role in the hemodynamic instability frequently seen during this procedure. A modified pulmonary artery catheter equipped with a fast response thermistor was used to determine RV ejection fraction (EFrv), allowing for calculation of RV end-diastolic volume index (EDVIrv, as the ratio of stroke index [SI] to EFrv) and RV end-systolic volume index (ESVIrv, as the difference between EDVIrv and SI). The above hemodynamic measures were taken during dissection for hepatectomy (stage I), during the anhepatic stage (stage II), and after reperfusion of the grafted liver, the neohepatic stage (stage III). No patient had pulmonary hypertension during the study interval. No correlation was observed between right atrial pressure (Pra) and EDVIrv, indicating that Pra is a less reliable clinical indicator of RV preload. RV function appeared to be well preserved throughout the procedure, as indicated by a relatively constant and supranormal EFrv, although a small and probably clinically unimportant decrease in EFrv was observed during the anhepatic stage (0.52, 0.50, and 0.55 during stages I, II, and III, respectively). There was a strong correlation between SI and EDVIrv for pooled data over a wide range of EDVIrv (60-185 mL.m-2). Although unstable central blood temperature precluded the determination of EFrv within the first 5 min after reperfusion, RV function was unaltered otherwise during uncomplicated orthotopic liver transplantation using venovenous bypass, indicating that orthotopic liver transplantation per se is not associated with significant RV dysfunction.
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Affiliation(s)
- A M De Wolf
- Department of Anesthesiology and Critical Care Medicine, University of Pittsburgh School of Medicine, Pennsylvania
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Seifert RD, Kang YG, Begliomini B, Miller SR. Baseline cardiac index does not predict hemodynamic instability during orthotopic liver transplantation. Transplant Proc 1989; 21:3523-4. [PMID: 2662508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- R D Seifert
- Department of Anesthesiology, University of Pittsburgh School of Medicine, PA 15261
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Aggarwal S, Kang Y, Freeman J, DeWolf AM, Begliomini B. Is there a post-reperfusion syndrome? Transplant Proc 1989; 21:3497-9. [PMID: 2662497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- S Aggarwal
- Department of Anesthesiology, University of Pittsburgh School of Medicine, PA 15261
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Cuccurullo F, Mezzetti A, Masi M, Rosini R, Fontana F, Begliomini B, Tomassetti V, Descovich GC, Lenzi S. [Effects of the combination of digitalis and carbochromen on cardiac metabolism in angina pectoris]. Minerva Cardioangiol 1978; 26:367-78. [PMID: 673192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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