Unlocking the enigma: Combined percutaneous-transhepatic and endoscopic strategies for retrieval of severed Dormia basket in choledocholithiasis. A case report and literature review

Choledocholithiasis, characterized by the presence of stones in the common bile duct, poses significant challenges in clinical management, particularly when the stones are massive. While endoscopic methods are often effective in stone removal, complications such as the impaction of foreign bodies like Dormia baskets can occur. These complications may necessitate alternative approaches, including surgical intervention, highlighting the importance of exploring innovative interventional techniques. We report on an 89-year-old patient presenting with massive choledocholithiasis, involving complete filling of the intra- and extrahepatic bile duct system with large stones up to a maximum of 2 cm. The patient underwent interventional removal of a Dormia basket (3.5Fr. Boston Scientific, USA) impacted in the common bile duct. This procedure proved challenging due to the metallic end marker of the basket perforating through the wall of the distal common bile duct, rendering it fixed. Given the complexity of the case, a parallel approach combining percutaneous transhepatic cholangiography and drainage with simultaneous endoscopy was employed to successfully extract the fixed Dormia basket. In cases of severe choledocholithiasis complicated by the impaction of foreign bodies such as Dormia baskets, innovative interventional strategies are crucial for successful management. Our case highlights the effectiveness of a parallel approach involving percutaneous transhepatic cholangiography and drainage alongside simultaneous endoscopy in safely removing the fixed foreign body from the common bile duct. This multidisciplinary approach not only offers a viable alternative to surgical intervention but also underscores the importance of collaboration between interventional radiologists and endoscopists in optimizing patient outcomes in complex biliary interventions.

Pancreaticobiliary Diseases with Severe Complications as a Rare Indication for Emergency Pancreaticoduodenectomy: A Single-Center Experience and Review of the Literature

The pancreaticobiliary system is a complex and vulnerable anatomic region. Small changes can lead to severe complications. Pancreaticobiliary disorders leading to severe complications include malignancies, pancreatitis, duodenal ulcer, duodenal diverticula, vascular malformations, and iatrogenic or traumatic injuries. Different therapeutic strategies, such as conservative, interventional (e.g., embolization, stent graft applications, or biliary interventions), or surgical therapy, are available in early disease stages. Therapeutic options in patients with severe complications such as duodenal perforation, acute bleeding, or sepsis are limited. If less invasive procedures are exhausted, an emergency pancreaticoduodenectomy (EPD) can be the only option left. The aim of this study was to analyze a single-center experience of EPD performed for benign non-trauma indications and to review the literature concerning EPD. Between January 2015 and January 2022, 11 patients received EPD due to benign non-trauma indications at our institution. Data were analyzed regarding sex, age, indication, operative parameters, length of hospital stay, postoperative morbidity, and mortality. Furthermore, we performed a literature survey using the PubMed database and reviewed reported cases of EPD. Eleven EPD cases due to benign non-trauma indications were analyzed. Indications included peptic duodenal ulcer with penetration into the hepatopancreatic duct and the pancreas, duodenal ulcer with acute uncontrollable bleeding, and penetration into the pancreas, and a massive perforated duodenal diverticulum with peritonitis and sepsis. The mean operative time was 369 min, and the median length of hospital stay was 35.8 days. Postoperative complications occurred in 4 out of 11 patients (36.4%). Total 90-day postoperative mortality was 9.1% (1 patient). We reviewed 17 studies and 22 case reports revealing 269 cases of EPD. Only 20 cases of EPD performed for benign non-trauma indications are reported in the literature. EPD performed for benign non-trauma indications remains a rare event, with only 31 reported cases. The data analysis of all available cases from the literature revealed an increased postoperative mortality rate of 25.8%. If less invasive approaches are exhausted, EPD is still a life-saving procedure with acceptable results. Performed by surgeons with a high level of experience in hepatobiliary and pancreatic surgery, mortality rates below 10% can be achieved.

Successful heparin-perfusion therapy for complete thrombosis of the intra- and extrahepatic portal and mesenteric vein. A case report and literature review

The initial treatment of acute and subacute portal vein thrombosis, which is the most common cause of portal vein occlusion, consists of intravenous anticoagulation with heparin, but there is still a huge uncertainty among physicians regarding the role of more invasive therapies. We report a 61-year-old male patient, who presented in our emergency room with a subacute complete thrombosis of the intra- and extrahepatic portal vein, mesenteric vein, with associated venous congestion of 20-30 cm length of the small intestine with a quick and complete remission of the portal vein thrombosis under sole i.v. heparin-perfusor therapy without any complications. Molecular genetic analysis found combined genetic mutations of the gene factor 2 (c.20210G>A, heterozygotic), SERPINE1 (-675 5G>4G, heterozygotic), and the MTHFR gene. Along with this interesting case, we also present the recent status of portal vein thrombosis and portal vein occlusion in the literature.

[Surgical treatment of chronic pancreatitis: indications, timing, methods]

The review is devoted to complex treatment of chronic pancreatitis considering modern data on pathogenesis of this disease. The authors analyze various aspects of endoscopic and surgical interventions in refractory pain syndrome and complications of chronic pancreatitis, as well as positive and negative aspects of each method. Various surgical interventions and indications are analyzed in detail. One of the important points was analysis of the period between disease onset and surgical treatment that affects quality of life in patients with chronic pancreatitis in mid- and long-term period.

[Interventions for pancreatitis]

Approximately 20% of patients with acute pancreatitis develop complications that require surgical or radiological intervention. Radiology plays a central role, not only for imaging (course of the disease, detection of superinfection and their related complications, and development of necrosis) but also for the treatment of vascular and nonvascular complications. In the treatment of severe or necrotizing pancreatitis, a multidisciplinary staged approach with minimally invasive therapies such as endoscopic or percutaneous drainage should be used. Applying a sufficient number of drains of sufficient size, strict irrigation therapy under computed tomographic (CT) control and repositioning of the drains can successfully treat pancreatic and peripancreatic necrosis often without the need for subsequent surgical debridement. Arterial complications affect 1-10% of all patients with pancreatitis, most of which are ruptured pseudoaneurysms, which represent the most dangerous bleeding complication of pancreatitis and can be treated with a high technical success rate through embolization and/or use of an endovascular stent-graft.

Quality of life in peritoneal carcinomatosis: a prospective study in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC)

BACKGROUND/AIMS

Cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion (HIPEC) can improve survival in selected patients with peritoneal carcinomatosis, but bear a significant risk of perioperative morbidity. The aim of this study was to prospectively evaluate the quality of life (QoL) following cytoreduction and HIPEC.

METHODS

In this study including 40 patients (65% females) with different primary tumors, the EORTC QLQ-C30 questionnaire was applied prior to CS and HIPEC as well as 3, 9, and 18 months postoperatively.

RESULTS

Global health status was not impaired significantly following HIPEC. Scales and symptom scores that deteriorated 3 months postoperatively (p < 0.05), that is, physical, role, and social functions as well as fatigue, pain, dyspnea, insomnia, and diarrhea, all returned to preoperative values within 9 months.

CONCLUSIONS

Following cytoreductive surgery and HIPEC, QoL returns to preoperative levels within 9 months. Selected patients that are likely to benefit oncologically from HIPEC should not be denied this option for fear of reduced postoperative QoL.

Impact of cyclosporine versus tacrolimus on the incidence of de novo malignancy following liver transplantation: a single center experience with 609 patients

De novo malignancies are a major cause of late death after liver transplantation. Aim of the present study was to determine whether use of cyclosporine versus tacrolimus affects long-term tumor incidence considering potential confounders. De novo malignancies in 609 liver transplant recipients at Munich Transplant Centre between 1985 and 2007 were registered. In 1996, the standard immunosuppressive regimen was changed from cyclosporine to tacrolimus. Different effects of those drugs on long-term tumor incidence were analyzed in multivariate analysis. During 3765 patient years of follow-up (median 4.78 years), 87 de novo malignancies occurred in 71 patients (mean age 47.5 ± 13.3 years, mean time after liver transplantation 5.7 ± 3.7 years). The cumulative incidence of de novo malignancies was 34.7% for all tumor entities after 15 years as compared to 8.9% for a nontransplanted population. The most frequent tumors observed were nonmelanoma skin cancers (44.83%). Moreover, post-transplant lymphoid disease, oropharyngeal cancer (n = 6, 6.9%), upper gastrointestinal tract cancer (n = 4, 4.6%), lung cancer (n = 4, 4.6%), gynecological malignancies (n = 4, 4.6%), and kidney cancer (n = 3, 3.45%) were detected. Multivariate analysis revealed recipient age [hazards ratio (HR) 1.06], male gender (HR 1.73), and tacrolimus-based immunosuppression (HR 2.06) as significant risk factors. Based on those results, a tacrolimus-based immunosuppression should be discussed especially in older male patients. Whether reducing tacrolimus target levels may reduce the risk for de novo malignancies has yet to be determined in prospective trials.

Surgery for metastasis to the pancreas: is it safe and effective?

BACKGROUND

Pancreatic metastases are rare and only sparse data exists on treatment options. After recent advances in pancreatic surgery, metastasectomies have become promising treatment alternatives.

METHODS

Twenty-six patients underwent pancreatic metastasectomy between 1991 and 2010 at our institution. Data was evaluated retrospectively.

RESULTS

Renal cell carcinoma was the most common origin of pancreatic metastases (n = 16; 62%). Other primaries include gall bladder carcinoma, leiomyosarcoma, colon cancer (all n = 2), and others. The median time interval between primary tumor and pancreatic resection was 5.3 years [0-24]. Eleven pancreatic head resections (42%), fourteen distal pancreatectomies (54%), and one total pancreatectomy were performed (4%). The estimated 3- and 5-year survival rates were 73.2% and 52.3%, respectively. The estimated median overall survival was 63 months (CI: 37.8-88.1 months). There' was no perioperative death. The complication rate and relaparotomy rate was 31% and 19%, respectively. Patients suffering from synchronous metastases at the time of pancreatic surgery had a statistically significant shorter median overall survival time (11 months vs. 64 months).

CONCLUSIONS

Despite the operative risk involved, we believe that pancreatic resection should be considered in selected patients with good performance status, stable disease and isolated pancreatic metastases.

Acute liver failure, rupture and hemorrhagic shock as primary manifestation of advanced metastatic disease

BACKGROUND

Malignancies rarely cause of acute liver failure, the presence of which have to be ruled-out during transplant evaluation. Tumor-related liver ruptures sporadically occur and might further complicate patient management.

CASE REPORT

We report the case of a previously healthy 56-year-old male with complaints of abdominal pain. Initially, levels of liver enzymes were elevated, however, comprehensive imaging examinations revealed no gross abnormalities. As acute liver failure developed, transplantation was evaluated. Sudden liver rupture and hemorrhage forced the performance of an emergency laparotomy. Hepatectomy was planned, until a donor organ was allocated. Intraoperatively, the liver unexpectedly revealed diffuse tumor infiltration. Without further therapeutical options, the patient died. Immunohistochemistry showed metastatic infiltration of a carcinoma of unknown primary.

CONCLUSION

Even in previously healthy patients suffering from acute liver failure, exclusion of malignancies is mandatory before transplantation. As imaging might be misleading, a biopsy should be considered early in unresolved cases.

β-Catenin mutations in 2 nested stromal epithelial tumors of the liver--a neoplasia with defective mesenchymal-epithelial transition

Nested stromal epithelial tumor of the liver is a rare neoplasm of early childhood and adolescence with a characteristic nested morphology of spindle and epithelioid cells. Histogenesis and pathogenesis of this neoplasm are, however, still unclear. Because the characteristic nested morphology with spindle mesenchymal and epithelioid cells is suggestive of altered mesenchymal-epithelial transition and β-catenin mutations are rather common in other liver tumors such as hepatoblastomas, we investigated the β-catenin gene in 2 nested stromal epithelial tumors of the liver and analyzed additional factors involved in mesenchymal-epithelial transition, such as E-cadherin, vimentin, c-Met, TWIST, SNAIL, and SLUG by molecular genetic and immunohistochemical methods. Mutation analysis of both cases revealed large deletions in exon 3 of the β-catenin gene (155 and 228 base pairs), resulting in an accumulation of β-catenin in the cytoplasm and nuclei of tumor cells, as evidenced by immunohistochemistry. The expression of the mesenchymal-epithelial transition factors SNAIL, SLUG, TWIST, c-Met, vimentin, and β-catenin was generally increased, whereas E-cadherin was decreased. Morphological and immunohistochemical analysis, however, showed a variable expression pattern of various epithelial and mesenchymal markers both in the spindle and epithelioid cell compartments of the tumors, thus illustrating the transitional status of the tumor cells. In conclusion, our data clearly identify protein stabilizing mutations of the β-catenin gene as a common feature of nested stromal epithelial tumors of the liver, similarly as in hepatoblastomas. Therefore, nested stromal epithelial tumors of the liver may be regarded as a variant of hepatoblastoma, despite differing from it in clinical and morphological aspects. The characteristic epithelioid-spindle morphology along with the incomplete epithelial differentiation proposes impaired mesenchymal-epithelial transition as a possible pathogenetic mechanism of this rare tumor. However, because only 2 cases were studied, this hypothesis awaits further validation.

Arterial blood flow predicts graft survival in liver transplant patients

Proper liver perfusion is essential for sufficient organ function after liver transplantation. The aim of this study was to determine the effects of portal and arterial blood flow on liver function and organ survival after liver transplantation. The arterial and portal venous blood flow was measured intraoperatively by transit time flow measurement after reperfusion for 290 consecutive liver transplants. The graft survival, hepatic cell damage (alanine aminotransferase and aspartate aminotransferase), and liver function (prothrombin ratio and bilirubin) were determined. Grafts were stratified into groups according to arterial blood flow measurements [<100 mL/minute for arterial blood flow group I (ART I), 100-240 mL/minute for ART II, and ≥ 240 mL/minute for ART III] and portal venous blood flow measurements (<1300 mL/minute for portal venous blood flow group I and ≥ 1300 mL/minute for portal venous blood flow group II). With multivariate analysis, the impact of blood flow on graft survival was determined, and potential confounders were considered. Decreased portal venous blood flow was associated with significantly less organ survival in univariate analysis but not in multivariate analysis. In contrast, the arterial blood flow was significantly correlated with organ survival after liver transplantation in univariate and multivariate analyses [hazard rate ratio = 2.5, confidence interval = 1.6-4.1, P < 0.001, median survival = 56.6 (ART I), 82.7 (ART II), or 100.7 months (ART III)]. Moreover, low arterial blood flow resulted in impaired postoperative organ function and higher rates of primary nonfunction. Biliary complications were not affected by blood flow. Other risk factors for graft failure that were identified by multivariate analysis included retransplantation, histidine tryptophan ketoglutarate solution versus University of Wisconsin solution, and donor treatment with epinephrine. Impaired arterial blood flow after reperfusion represents a significant predictor of primary graft nonfunction and is associated with impaired graft survival. Whether the intraoperative measurement of hepatic arterial flow is predictive of graft survival should be evaluated in a prospective trial.

Late reuse of liver allografts from brain-dead graft recipients: the Munich experience and a review of the literature

The increasing donor organ shortage requires the consideration of any possible organ donor in order to meet the current demand. However, the growing number of long-term survivors of liver transplantation may create a situation in which former organ recipients may experience brain death with a functioning graft and therefore become organ donors themselves. Previous reports concerning this rare situation predominantly refer to the reuse of donor organs within the first 8 days after primary liver transplantation. So far, only a single case of late reuse of a donor liver has been published, with 2 additional cases mentioned in a summary of the United Network for Organ Sharing database. Here we report the case of a 43-year-old female donor who had received a liver graft for complications of Budd-Chiari syndrome 5 years before becoming an organ donor herself after cerebral infarction with consecutive brain death.

A prospective randomised, open-labeled, trial comparing sirolimus-containing versus mTOR-inhibitor-free immunosuppression in patients undergoing liver transplantation for hepatocellular carcinoma

Background

The potential anti-cancer effects of mammalian target of rapamycin (mTOR) inhibitors are being intensively studied. To date, however, few randomised clinical trials (RCT) have been performed to demonstrate anti-neoplastic effects in the pure oncology setting, and at present, no oncology endpoint-directed RCT has been reported in the high-malignancy risk population of immunosuppressed transplant recipients. Interestingly, since mTOR inhibitors have both immunosuppressive and anti-cancer effects, they have the potential to simultaneously protect against immunologic graft loss and tumour development. Therefore, we designed a prospective RCT to determine if the mTOR inhibitor sirolimus can improve hepatocellular carcinoma (HCC)-free patient survival in liver transplant (LT) recipients with a pre-transplant diagnosis of HCC.

Methods/Design

The study is an open-labelled, randomised, RCT comparing sirolimus-containing versus mTOR-inhibitor-free immunosuppression in patients undergoing LT for HCC. Patients with a histologically confirmed HCC diagnosis are randomised into 2 groups within 4-6 weeks after LT; one arm is maintained on a centre-specific mTOR-inhibitor-free immunosuppressive protocol and the second arm is maintained on a centre-specific mTOR-inhibitor-free immunosuppressive protocol for the first 4-6 weeks, at which time sirolimus is initiated. A 2^1/2 -year recruitment phase is planned with a 5-year follow-up, testing HCC-free survival as the primary endpoint. Our hypothesis is that sirolimus use in the second arm of the study will improve HCC-free survival. The study is a non-commercial investigator-initiated trial (IIT) sponsored by the University Hospital Regensburg and is endorsed by the European Liver and Intestine Transplant Association; 13 countries within Europe, Canada and Australia are participating.

Discussion

If our hypothesis is correct that mTOR inhibition can reduce HCC tumour growth while simultaneously providing immunosuppression to protect the liver allograft from rejection, patients should experience less post-transplant problems with HCC recurrence, and therefore could expect a longer and better quality of life. A positive outcome will likely change the standard of posttransplant immunosuppressive care for LT patients with HCC.

Trial Register

Trial registered at http://www.clinicaltrials.gov: NCT00355862

(EudraCT Number: 2005-005362-36)

[Diagnosis and multimodal therapy for hepatocellular carcinoma]

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related death in the world. The majority of HCCs develops on the basis of a chronic liver disease. This often complicates diagnosis and therapy. Non-invasive diagnostic criteria are based on dynamic imaging techniques and the serum level of AFP (alpha-fetoprotein). When evaluating HCC patients for therapy, besides tumor burden and localisation, the therapeutic evaluation must also consider the general condition of the patient and his/her liver function. For this purpose, the BCLC algorithm of the Barcelona Clinic for Liver Disease has proven helpful. Only one-third of the patients can be cured by resection, transplantation or local tumour ablation. In locally advanced cases transarterial procedures including transarterial chemoembolisation and radioembolisation are applied. HCC is a chemo-resistant tumour and chemotherapy is not accepted as standard of care in HCC. Sorafenib is the first systemic treatment with proven efficacy approved for the treatment of advanced and metastatic HCC. Interdisciplinary management of HCC patients is essential in order to provide every patient with the optimal therapy at his specific stage of disease.

Contrast-enhanced ultrasound in liver transplant: first results and potential for complications in the postoperative period

PURPOSE

This study compared the efficacy of contrast-enhanced ultrasound (CEUS) using a second generation contrast medium versus CT or MRA in the assessment of vascular and biliary complications in postoperative follow-up of liver transplantation.

METHODS AND MATERIALS

The study group consisted of 36 consecutive liver transplant recipients who underwent post-transplantation CEUS examination after developing ascites and/or unclear liver function tests. Real time CEUS was performed after a bolus injection of SonoVue (1.6-2.4 ml, Bracco, Imaging Germany) followed by 10 ml of saline solution. Using contrast harmonic imaging (CHI) technique (Logiq 9, GE) with a 2.5-4-MHz transducer, a low mechanical index was chosen to avoid early destruction of the microbubbles (MI 0.1-0.2). In order to confirm the results, the patients underwent contrast-enhanced MRI or CT.

RESULTS

Complications were identified in 16 of 36 patients (44.4%). Five transplants (14%) had hepatic artery thrombosis (n=2) or significant stenosis (n=3). Six transplants (16%) developed portal vein stenosis (n=4) or portal vein thrombosis (n=2). MRI or CT confirmed the findings of the CEUS in all 11 cases. Biliary stricture at the anastomotic site was detected in 5 patients. MR-CP confirmed the findings of all strictures.

CONCLUSION

Due to advances in contrast-enhanced US, vascular and biliary complications in the postoperative period following liver transplantation can be reliably diagnosed non-invasively on the intensive care unit. CEUS shows vascular as well as biliary complications in the postoperative patient with a high degree of accuracy.

[Usage of marginal organs for liver transplantation: a way around the critical organ shortage?]

The transplantation of marginal organs or those meeting the so-called extended donor criteria (EDC) is today a significant option to alleviate the low availability or organs and to increase the number of transplantation which in turn is -accompanied by a lower mortality among wait-ing-list patients. However such an extension of the spender pool carries the risks of an increased incidence of organ dysfuntions and a higher recipient mortality. This situation presents an ethical problem when marginal organs are accepted for transplantation because the anticipated mortality for the individual recipient cannot be determined. The transplantation of marginal organs from -donors with a high MELD score seems to be linked to a higher mortality. In particular, the combina-tions of high donor age and long ischaemic time or advanced donor age and hepatitis C infection in the recipient are definitively associated with a significantly poorer organ survival rate. In view of the serious lack of organs, efforts should be made, for example, by shortening of the is-chae-mic time and the development of therapeutic strategies, to improve the function and increase the number of usable marginal organs and thus to increase pool of donor organs. The refusal of marginal organs on the basis of individual EDC without consideration of the status of recipient does not seem to be adequate.

The dark side of the moon: impact of moon phases on long-term survival, mortality and morbidity of surgery for lung cancer

Objective

Superstition is common and causes discomfiture or fear, especially in patients who have to undergo surgery for cancer. One superstition is, that moon phases influence surgical outcome. This study was performed to analyse lunar impact on the outcome following lung cancer surgery.

Methods

2411 patients underwent pulmonary resection for lung cancer in the past 30 years at our institution. Intra-and postoperative complications as well as long-term follow-up data were entered in our lung-cancer database. Factors influencing mortality, morbidity and survival were analyzed.

Results

Rate of intra-operative complications as well as rate of post-operative morbidity and mortality was not significantly affected by moon phases. Furthermore, there was no significant impact of the lunar cycle on long-term survial.

Conclusion

In this study there was no evidence that outcome of surgery for lung cancer is affected by the moon. These results may help the physician to quite the mind of patients who are somewhat afraid of wrong timing of surgery with respect to the moon phases. However, patients who strongly believe in the impact of moon phase should be taken seriously and correct timing of operations should be conceded to them as long as key-date scheduling doesn't constrict evidence based treatment regimens.

Esophageal leiomyomatosis combined with intrathoracic stomach and gastric volvulus

CASE REPORT

A 42-year-old female presented with long-standing symptoms suggestive of gastroesophageal reflux disease improved after proton pump inhibitor treatment. An upper endoscopy revealed an intrathoracic position of the stomach (type 4 hiatal hernia) with no mucosal abnormality. Barium swallow demonstrated gastric herniation with gastric volvulus without stenosis. A computed tomographic scan confirmed the intrathoracic location of the stomach associated with thickening and edema of the gastric wall due to gastric volvulus, but no evidence of malignancy. The patient was scheduled for laparoscopic gastric repositioning with anterior hemifundoplication. Due to the incidental intraoperative finding of a large distal esophageal tumor (frozen section: esophageal leiomyomatosis), the operation was converted to conventional distal esophagectomy and proximal gastrectomy with reconstruction using a Merendino procedure. Final histology revealed extensive circumferential leiomyomatosis of the distal esophagus with a diameter of 10 cm. Esophageal leiomyomatosis is an extremely rare pathological finding with <100 cases reported in the literature.

CONCLUSION

Any surgeon performing laparoscopic fundoplication has to be ready to deal with such unexpected findings, ie, converting the procedure and doing reconstruction with minimal morbidity. The Merendino procedure is a well-established reconstructive surgical option in cases of tumor formation at the gastroesophageal region with fewer postoperative morbidities like reflux symptoms.

Multifocal manifestation does not affect vascular invasion of hepatocellular carcinoma: implications for patient selection in liver transplantation

BACKGROUND AND AIMS

Liver transplantation (OLT) for hepatocellular carcinoma (HCC) improves patient survival when tumor size and number are limited according to the Milan criteria. However, the impact of tumor size vs. the number of lesions for tumor recurrence after OLT is unclear. Microvascular invasion appears to be a significant risk factor for tumor recurrence. Therefore, it was the aim of this study to investigate tumor differentiation and microvascular invasion in relation to tumor number and size and their impact on survival after transplantation.

PATIENTS AND METHODS

In 97 adult HCC patients who underwent OLT between June 1985 and December 2005 the incidence of microvascular invasion, tumor differentiation, and the number and size of tumor lesions were analyzed retrospectively. Their impact on survival was studied by multivariate analysis.

RESULTS

Microvascular invasion was the only independent negative predictor of survival after OLT for HCC (p = 0.025). Tumor size > 5 cm was predictive for microvascular invasion (p = 0.007). In contrast, tumor number did not affect the incidence of microvascular invasion or cumulative survival.

CONCLUSION

The size of the largest HCC lesion, but not the number of tumors, determined microvascular invasion, a predictor of the outcome following OLT for HCC. Thus, the number of HCC lesions should not be applied to patient selection prior to OLT. These data support the extension of the Milan criteria for the selection of HCC patients for OLT with regard to tumor number, but not tumor size.

Effect of graft steatosis on liver function and organ survival after liver transplantation

BACKGROUND

It was the aim to determine the effect of graft steatosis on intraoperative organ blood flow, postoperative liver function, and organ survival.

METHODS

A total of 225 consecutive liver transplants were reviewed. Liver blood flow, hepatic function (AST, ALT, prothrombin time), and organ survival were determined. Donor liver grafts were categorized into 2 subgroups: mild (<30%) (n = 175) and moderate to severe (>/=30%) (n = 50) macrovesicular steatosis.

RESULTS

Moderate to severe steatosis was associated with significantly increased AST and ALT levels and significantly diminished prothrombin time on the first and second postoperative day. By day 7 differences in liver function were no longer evident. Organ blood flow was not affected by steatosis. After adjustment for potential confounders, organ survival did not depend on the degree of donor steatosis (5-year-survival rates: 68% and 58% with steatosis <30%, or >/= 30%, respectively) (hazard ratio .754, confidence interval .458-1.242, P = .268).

CONCLUSION

Steatotic livers can be transplanted safely with good results for long-term organ survival if other contraindications are absent.

Surgery in immunocompromised patients

Aging, immune disease and transplantation are discussed

The University of Munich lung cancer group database: design, profile of cohort and outcome analysis

OBJECTIVE

Changes in therapeutic concepts can only be justified by a significant improvement of outcome parameters. Furthermore, detailed statistics of complications are needed to guarantee high quality of treatment. This study describes the new University of Munich Lung Cancer Group Database.

METHODS

The MLCG-Database contains all patients who underwent surgery for lung cancer at the Department of Surgery, University of Munich Medical Centre since 1978. Data were database recorded on the patient's ward, or directly imported from other departments performing medical examinations on the patient. Data could be entered online at the time of surgery in the operating room. Relevant information from the Munich Tumour Registry was imported via encrypted data communication. Both epidemiological background and influence of preoperative risk factors on morbidity and mortality as well as on long-term survival were analysed.

RESULTS

Median follow-up time was 45 months (1-295 months). Overall 5- and 10-year survival was 36% and 28% respectively. Preoperative risk factors were arterial hypertension in 43% of patients, COPD in 34%, abuse of nicotine in 26% and therapy with corticosteroids in 25%. Surgical procedure consist of lobectomy or bilobectomy in 69%, pneumonectomy in 16% and lesser resections in 15%. Intra- and postoperative complications occurred in 1.4% and 32% of patients, respectively.

CONCLUSIONS

This paper provides an overview of our MLCG-Database, which allows performing statistics for outcome analysis and quality management reports as well as medical assessment on a huge collection of patient data on a day-to-day basis. In addition, impact analysis of risk factors on postoperative morbidity and mortality as well as investigation of long-term survival underlines results reported internationally.

Liver resection or combined chemoembolization and radiofrequency ablation improve survival in patients with hepatocellular carcinoma

BACKGROUND/AIMS

To evaluate the long-term outcome of surgical and non-surgical local treatments of patients with hepatocellular carcinoma (HCC).

METHODS

We stratified a cohort of 278 HCC patients using six independent predictors of survival according to the Vienna survival model for HCC (VISUM-HCC).

RESULTS

Prior to therapy, 224 HCC patients presented with VISUM stage 1 (median survival 18 months) while 29 patients were classified as VISUM stage 2 (median survival 4 months) and 25 patients as VISUM stage 3 (median survival 3 months). A highly significant (p < 0.001) improved survival time was observed in VISUM stage 1 patients treated with liver resection (n = 52; median survival 37 months) or chemoembolization (TACE) and subsequent radiofrequency ablation (RFA) (n = 44; median survival 45 months) as compared to patients receiving chemoembolization alone (n = 107; median survival 13 months) or patients treated by tamoxifen only (n = 21; median survival 6 months). Chemoembolization alone significantly (p < or = 0.004) improved survival time in VISUM stage 1-2 patients but not (p = 0.341) in VISUM stage 3 patients in comparison to those treated by tamoxifen.

CONCLUSION

Both liver resection or combined chemoembolization and RFA improve markedly the survival of patients with HCC.

[A method for reassessment of cost-intensive cases in visceral surgery. Results of project by the German Society for Visceral Surgery]

Since the introduction of diagnosis-related groups (DRGs) many surgical departments report inappropriate reimbursement for complex cases and a shift in costly cases. To evaluate this situation, the German Society for Visceral Surgery inaugurated the present cost calculation project. In three university hospitals for 50 cases each, we depicted possible cost separators and utilized the complete cost calculation data (so-called Paragraph 21 data set) to test these separators. We identified "admission from another hospital", "severe surgically relevant concomitant disease", and "reoperation during the same hospital admission". The last was considered the economically most significant and medically most valid factor and was submitted as a possible modification to the german DRG system. The proposed cost separator "reoperation during the same hospital admission" was introduced into the DRG system after validation and leads to better allocation of reimbursements to complex and costly cases.

Five-Year Follow-up After Late Conversion From Calcineurin Inhibitors to Sirolimus in Patients With Chronic Renal Allograft Dysfunction

BACKGROUND

Chronic allograft nephropathy (CAN) is, among others, caused by nephrotoxic side effects of calcineurin inhibitors (CNI), which are to date still the mainstay of immunosuppressive therapy. Sirolimus (SIR), an immunosuppressive compound without effects on glomerular perfusion, has been used in CNI-sparing immunosuppressive protocols. We report the 5-year follow-up of a prospective, controlled conversion study from CNI to SIR in patients with moderately to severely impaired renal function.

METHODS

Twelve renal transplant recipients with moderately to severely impaired renal function (estimated glomerular filtration rate of 17 to 35 mL/min according to the MDRD formula), enrolled in a prospective, controlled 1-year pilot study were followed for 5 years.

RESULTS

Three renal grafts (25%) were lost during the 5-year follow-up. Graft loss was due to noncompliance in one patient and to CAN in the other two patients. These two patients returned to dialysis 43 and 59 months after conversion, corresponding to 86 and 75 months after transplantation, respectively. Six of nine patients had a stable or even better renal function compared to the baseline. The lipid profile increased initially, but then remained stable over time.

CONCLUSION

Conversion of immunosuppressive therapy from CNI to SIR in patients with impaired renal function more than 1 year after transplantation is feasible and safe yielding improved renal function in the majority of patients, which was sustained at 5 years follow-up.

The janus face of immunosuppression - de novo malignancy after renal transplantation: the experience of the Transplantation Center Munich

After decades of successful organ transplantation clinicians continue to be troubled by the increasing incidence of cancers under maintenance immunosuppression. In this study, we examined rates of malignancies in 2419 renal transplant recipients transplanted in our institution between 1978 and 2005. In renal transplant recipients the cumulative incidence of cancer after 25 years was 49.3% for all tumors and 39.7% excluding non-melanoma skin cancers, compared with 21% for a normal sex- and age-matched population. The most frequent tumors observed were non-melanoma skin cancers (20.5%), kidney cancers (12.0%), and cancers of the pharynx, larynx, or oral cavity (8.2%). The general increase of cancer risk was 4.3-fold. Independent risk factors for the development of a tumor were male gender, older recipient age, the presence of preformed antibodies before transplantation, and the time on immunosuppression. Interestingly, the use of IL-2-receptor antagonists significantly reduced the tumor risk of transplant recipients. The tumor risk between immunosuppressive drugs typically used for maintenance immunosuppression was not significantly different. However, mammalian target of rapamycin (mTOR) inhibitor-based immunosuppressive protocols showed a clear tendency for lower malignancy rates. De novo malignancies following renal transplantation represent a serious problem endangering the prognosis of otherwise successfully transplanted patients. Future studies will have to address whether optimized immunosuppressive regimens including mTOR-inhibitors are capable of reducing the incidence or preventing the development of posttransplant malignancies.

Inhibition of the mammalian target of rapamycin impedes lymphangiogenesis

Lymphatic complications are common side effects of mammalian target of rapamycin (mTOR) inhibitor-based immunosuppression in kidney transplantation. Therefore, we investigated whether the mTOR inhibitor rapamycin, besides its known antihemangiogenic effect, also impedes regenerative lymphangiogenesis. In a murine skin flap model, rapamycin impaired recovery of lymphatic flow across surgical incisions resulting in prolonged wound edema in these animals. Importantly, the antilymphangiogenic effect of rapamycin was not related to a general inhibition of wound healing as demonstrated an in vivo Matrigeltrade mark lymphangiogenesis assay and a model of lymphangioma. Rapamycin concentrations as low as 1 ng/ml potently inhibited vascular endothelial growth factor (VEGF)-C driven proliferation and migration, respectively, of isolated human lymphatic endothelial cells (LECs) in vitro. Mechanistically, mTOR inhibition impairs downstream signaling of VEGF-A as well as VEGF-C via mTOR to the p70S6 kinase in LECs. In conclusion, we provide extensive experimental evidence for an antilymphangiogenic activity of mTOR inhibition suggesting that the early use of mTOR inhibitor following tissue injury should be avoided. Conversely, the antilymphangiogenic properties of rapamycin and its derivates may provide therapeutic value for the prevention and treatment of malignancies, respectively.

The immunosuppressant FTY720 inhibits tumor angiogenesis via the sphingosine 1-phosphate receptor 1

FTY720, a sphingosine 1-phosphate (S1P) analog, acts as an immunosuppressant through trapping of T cells in secondary lymphoid tissues. FTY720 was also shown to prevent tumor growth and to inhibit vascular permeability. The MTT proliferation assay illustrated that endothelial cells are more susceptible to the anti-proliferative effect of FTY720 than Lewis lung carcinoma (LLC1) cells. In a spheroid angiogenesis model, FTY720 potently inhibited the sprouting activity of VEGF-A-stimulated endothelial cells even at concentrations that apparently had no anti-proliferative effect. Mechanistically, the anti-angiogenic effect of the general S1P receptor agonist FTY720 was mimicked by the specific S1P1 receptor agonist SEW2871. Moreover, the anti-angiogenic effect of FTY720 was abrogated in the presence of CXCR4-neutralizing antibodies. This indicates that the effect was at least in part mediated by the S1P1 receptor and involved transactivation of the CXCR4 chemokine receptor. Additionally, we could illustrate in a coculture spheroid model, employing endothelial and smooth muscle cells (SMCs), that the latter confer a strong protective effect regarding the action of FTY720 upon the endothelial cells. In a subcutaneous LLC1 tumor model, the anti-angiogenic capacity translated into a reduced tumor size in syngeneic C57BL/6 mice. Consistently, in the Matrigel plug in vivo assay, 10 mg/kg/d FTY720 resulted in a strong inhibition of angiogenesis as demonstrated by a reduced capillary density. Thus, in organ transplant patients, FTY720 may prove efficacious in preventing graft rejection as well as tumor development.

Conversion from calcineurin inhibitors to sirolimus in patients with chronic renal allograft dysfunction

BACKGROUND

Chronic renal transplant dysfunction in part may be due to the nephrotoxic effects of calcineurin inhibitors, which are still the mainstay of immunosuppressive therapy. Sirolimus, a new immunosuppressive compound devoid of significant nephrotoxicity, might therefore exhibit beneficial effects when used in renal transplant recipients with graft dysfunction.

METHODS

Twelve renal transplant recipients included in this study had all been receiving calcineurin inhibitors for more than 12 months, and were free of rejection for more than 12 months. However, they demonstrated moderate renal dysfunction with serum creatinine values ranging from 1.8 to 4.0 mg/dL (164 to 351 micromol/L). After reaching a sirolimus level of 10 to 20 ng/mL, calcineurin inhibitor therapy was withheld.

RESULTS

One month after initiation of sirolimus therapy, all patients were off calcineurin inhibitors. The average daily sirolimus dosage was 5.8+/-3.4 mg. No acute rejection episode and no graft failure was observed. No patient required hemodialysis or admission to the hospital. Calculated creatinine clearance increased from 63.4+/-9.9 to 69.2+/-9.7 mL/min (P=.0368) and serum bicarbonate increased from 20.8+/-3.17 to 22.5+/-3.7 meq/L (P=.001). Serum cholesterol increased from 180+/-26.5 to 239+/-28.8 mg/dL (4.65+/-0.69 to 6.18+/-0.74 mmol/L, P<.001), triglycerides increased from 155+/-53 to 289+/-123 mg/dL (1.75+/-0.6 to 3.26+/-1.39 mmol/L) and low-density lipoprotein cholesterol increased from 99+/-32 to 131+/-25.1 mg/dL (2.56+/-0.83 to 3.39+/-0.65 mmol/L, P=.01). Arterial blood pressure remained well controlled (126+/-15.6/74+/-8.9 vs 134+/-16.8/83+/-9.7).

CONCLUSION

Conversion from calcineurin inhibitor therapy to sirolimus in patients more than 1 year after transplantation with impaired organ function is feasible, safe, and associated with a trend toward improved renal function.

B-Flow Sonography for Detecting Portal Venous Stenosis After Liver Transplantation

A case of a patient in his early 60s with a portal vein stenosis after liver transplantation (LTx) detected by sonography in B-flow mode is reported. Two weeks after LTx, the patient developed ascites and severe alteration of liver function tests. Color Doppler (CD) demonstrated a stenosis in the portal vein with a maximum flow of 340 cm/sec. Due to aliasing, correct assessment of stenosis diameter was not possible by means of CD. However, by using the B-flow imaging technique, slow and fast velocities in the pre-, intra-, and poststenotic segment could be detected without aliasing or overwriting. In addition, a second stenosis in the portal vein was identified. For the follow-up outcome of patients, it is essential to detect and treat this complication. After surgical intervention, graft function recovered and postoperative flow measurements showed a normal portal vein flow of 70 cm/sec in the poststenotic segment.

Biochemical monitoring of mTOR inhibitor-based immunosuppression following kidney transplantation: a novel approach for tailored immunosuppressive therapy

BACKGROUND

Immunosuppressive therapy with the mammalian target of rapamycin (mTOR) inhibitors requires a fine balance between allograft maintenance and drug-related side effects.

METHODS

In this study we examined the feasibility of monitoring TOR inhibitor-based immunosuppression by assessment of the phosphorylation status at the Thr(389) site of the p70S6 kinase in peripheral blood mononuclear cells (PBMCs). At total of 36 patients with renal transplants and 8 healthy controls were enrolled.

RESULTS

We found that sirolimus treatment was associated with a pronounced inhibition of p70S6 kinase phosphorylation, as compared to healthy donors or otherwise immunosuppressed patients. In sirolimus-treated patients, phosphorylation of the p70S6 kinase was significantly inhibited when sirolimus trough levels were > 6 ng/mL. In contrast, for trough levels <6 ng/mL, the degree of inhibition of p70S6 kinase phosphorylation showed a high degree of interindividual variability. We recorded a total of five clinical relevant rejection episodes in this patient category. Intriguingly, rejecters uniformly maintained a high degree of phosphorylation independent of the sirolimus trough level whereas non-rejecters showed a significant inhibition of phosphorylation.

CONCLUSION

Therefore, the phosphorylation status of the p70S6 kinase appears to provide more relevant information on the desired effect of sirolimus in target cells as compared to trough level measurements. Moreover, this assay provides an opportunity to safely titer down sirolimus levels to avoid overimmunosuppression and, on the other hand, to identify patients with insufficient TOR inhibitor therapy that are at risk for rejection.

mTOR Inhibition and its Effect on Cancer in Transplantation

A considerable amount of data indicates that transplanted patients are at increased risk for de novo and recurrent cancer. Treatment of this population is difficult. It remains unclear if the immunosuppressive therapy should be continued, tapered or even stopped or if immunosuppressive drugs with antiproliferative properties have beneficial effects in this situation. In various models, mTOR-inhibitors were shown to have immunosuppressive and anti-tumor effects. Here, we have reviewed the current literature trying to clarify if mTOR-inhibition brings advantages for the transplanted patients suffering from tumors.

Rapamycin induces tumor-specific thrombosis via tissue factor in the presence of VEGF

Therapeutic strategies that target and disrupt the already-formed vessel networks of growing tumors are actively pursued. The goal of these approaches is to induce a rapid shutdown of the vascular function of the tumor so that blood flow is arrested and tumor cell death occurs. Here we show that the mammalian target of rapamycin (mTOR) inhibitor rapamycin, when administered to tumor-bearing mice, selectively induced extensive local microthrombosis of the tumor microvasculature. Importantly, rapamycin administration had no detectable effect on the peritumoral or normal tissue. Intravital microscopy analysis of tumors implanted into skinfold chambers revealed that rapamycin led to a specific shutdown of initially patent tumor vessels. In human umbilical vein endothelial cells vascular endothelial growth factor (VEGF)–induced tissue factor expression was strongly enhanced by rapamycin. We further show by Western blot analysis that rapamycin interferes with a negative feedback mechanism controlling this pathologic VEGF-mediated tissue factor expression. This thrombogenic alteration of the endothelial cells was confirmed in a one-step coagulation assay. The circumstance that VEGF is up-regulated in most tumors may explain the remarkable selectivity of tumor vessel thrombosis under rapamycin therapy. Taken together, these data suggest that rapamycin, besides its known antiangiogenic properties, has a strong tumor-specific, antivascular effect in tumors.

FTY720 inhibits tumor growth and angiogenesis

De novo malignancies and recurrence of tumors are some of the biggest threats to allograft recipients subjected to chronic immunosuppression. FTY720, a synthetic myriocin analogue, is an immunosuppressant that induces apoptosis of activated lymphocytes and prevents infiltration of lymphocytes into allografts, thereby prolonging allograft survival in a dose-dependent manner. Additionally, FTY720 was shown to prevent tumor growth and metastasis. Therefore, we examined the effect of FTY720 on angiogenesis in a HUVEC spheroid model. To substantiate our in vitro findings the effect of FTY720 was also tested in C57/B16 mice subcutaneously injected with Lewis Lung Carcinoma (LLC1) cells. After establishment of a palpable tumor the animals were treated daily with either saline or 1, 5, or 10 mg/kg FTY720. Subsequently, the tumor size was measured, periodically. In our experiments FTY720 showed a strong antiangiogenic effect, overcoming the stimulating effect of VEGF (20 ng/mL) even at subnanomolar concentrations. In vivo, FTY720 showed a dose-dependent inhibition of subcutaneous tumors, and the tumor size of animals treated with 10 mg/kg FTY720 was less than half of the size of tumors in control animals. In conclusion, FTY-720 demonstrated a strong antiangiogenic effect in vitro and a substantial antitumor effect in vivo. Presumably, the stabilizing effect of surrounding pericytes limits the effect of FTY720 in our mouse model. Therefore, a combination of FTY720 with an mTOR inhibitor might be the most favorable immunosuppressive drug combination for allograft recipients at risk for tumor development.

Cyclosporine: 20 years of experience at the University of Munich

The history of solid organ transplantation is, from an immunotherapeutic standpoint, divided in the era before and after the introduction of cyclosporine to the clinic. The introduction of cyclosporine to the clinic in 1978 is looked upon as a turning point in transplantation. The immediate success of the new drug was based on the reduction of early graft rejection and the substantial improvement of 1-year graft survival. With growing experience in the use of this new compound, together with the ability to measure drug levels in serum, allograft rejection and organ survival could be improved even further. Because of the clinical results, cyclosporine became the gold standard in immunosuppressive therapy after organ transplantation. Even after 20 years, as more and more new immunosuppressants emerge, the clinical evaluation of a new drug is frequently compared versus a cyclosporine-based regimen. Today, cyclosporine is probably one of the best investigated drugs in the field of organ transplantation. Beside the undoubted benefits of cyclosporine, experimental and clinical studies have also revealed some unwanted effects, such as nephrotoxicity and an increased risk in development of malignant tumors. Here, we review the experience at our institution with transplant recipients receiving cyclosporine as the main immunosuppressant over the past 20 years.

Konsensusempfehlung zum Einsatz von Sirolimus in der Lebertransplantation

Sirolimus is an m-TOR inhibitor without renal side effects and potentially protects against the development of malignancy. Due to a higher incidence of complications in two trials and an official warning in the drug information, the use of Sirolimus in liver transplantation is limited. The participants of this consensus meeting had to analyse and evaluate the literature with respect to the potential role of Sirolimus in liver transplantation. This consensus statement follows the scheme normally employed for the presentation of guidelines including the grading of evidence (1a-5) and the extent of recommendation (A-C). Moreover, the consensus included the experience of the authors with respect to the handling of Sirolimus after liver transplantation.

Pro- and anti-cancer effects of immunosuppressive agents used in organ transplantation

Development of cancer is a feared, and increasingly apparent, complication of long-term immunosuppressive therapy in transplant recipients. In addition to the need to reduce cancer occurrence in these patients, therapeutic protocols are lacking to simultaneously attack the malignancy and protect the allograft when neoplasms do occur. In this overview, we present the current literature regarding the pro- and anti-neoplastic effects of immunosuppressive agents on cancer growth and development. Recent experimental findings are paving the way for new therapeutic strategies aimed at both protecting an allograft from immunologic rejection and addressing the problem of cancer in this high-risk population.

Rapamycin protects allografts from rejection while simultaneously attacking tumors in immunosuppressed mice

Cancer is an increasingly recognized problem associated with immunosuppression. Recent reports, however, suggest that the immunosuppressive agent rapamycin has anti-cancer properties that could address this problem. Thus far, rapamycin's effects on immunity and cancer have been studied separately. Here we tested the effects of rapamycin, versus cyclosporine A (CsA), on established tumors in mice simultaneously bearing a heart allograft. In one tumor-transplant model, BALB/c mice received subcutaneous syngenic CT26 colon adenocarcinoma cells 7 days before C3H ear-heart transplantation. Rapamycin or CsA treatment was initiated with transplantation. In a second model system, a B16 melanoma was established in C57BL/6 mice that received a primary vascularized C3H heart allograft. In vitro angiogenic effects of rapamycin and CsA were tested in an aortic ring assay. Results show that CT26 tumors grew for 2 weeks before tumor complications occurred. However, rapamycin protected allografts, inhibited tumor growth, and permitted animal survival. In contrast, CsA-treated mice succumbed to advancing tumors, albeit with a functioning allograft. Rapamycin's antitumor effect also functioned in severe combined immunodeficient BALB/c mice. Similar effects of the drugs occurred with B16 melanomas and primary vascularized C3H allografts in C57BL/6 mice. Furthermore, in this model, rapamycin inhibited the tumor growth-enhancing effects of CsA. Moreover, in vitro experiments showed that CsA promotes angiogenesis by a transforming growth factor-beta-related mechanism, and that this effect is abrogated by rapamycin. This study demonstrates that rapamycin simultaneously protects allografts from rejection and attacks tumors in a complex transplant-tumor situation. Notably, CsA protects allografts from rejection, but cancer progression is promoted in transplant recipients.

[Problems with the follow-up and aftercare of transplanted patients exemplified by kidney transplantation]

The large number of post-transplantation patients overwhelm the capacity of most transplantation centers (TC) to provide aftercare, with the result that close cooperation has been established between transplantation centers and ambulatory centers. Surveillance of immunosuppression, but also the treatment of concomitant cardiovascular diseases and the elevated tumorigenesis rate in transplanted patients, presuppose a high degree of readiness to undergo further education on a permanent basis. Furthermore, patient compliance is a factor of decisive importance for ensuring optimal care by the general physician. In close cooperation with the TC, the latter bears a considerable burden of responsibility for the lifelong aftercare of such patients.

Paclitaxel saves rat heart allografts from rejection by inhibition of the primed anti-donor humoral and cellular immune response: implications for transplant patients with cancer

Paclitaxel is an anti-neoplastic drug that was recently shown also to have immunosuppressive properties in naïve rat heart transplant recipients. Here, we tested whether paclitaxel could also effectively reverse an ongoing immune response in transplant recipients. We therefore used a model in which Lewis rat recipients receiving ACI rat heterotopic heart allografts were: (1) untreated, or treated with either (2) paclitaxel or (3) cyclosporine, starting 5 days after transplantation. Allograft survival was determined in one group, and in a second group cytotoxic T-lymphocyte (CTL) responses were determined and serum anti-donor cytotoxic antibody levels were measured. Results showed that paclitaxel was as effective as cyclosporine in saving recipients from imminent allograft rejection. Immunologically, paclitaxel reduced the allogeneic-CTL response, but most impressively, the cytotoxic antibody response was nearly eliminated in saved recipients. Therefore, paclitaxel's immunosuppressive properties, along with its known effectiveness against a wide variety of tumors, makes it potentially useful for the simultaneous treatment of rejection and neoplasms in cases of transplant-related cancer.

Early experience with the ET Senior Program "Old For Old"; better to be number one?

Eurotransplant offers a Senior Program to extend the donor pool for renal transplantation. The study comprised 14 patients of the ET Senior ("Old For Old") Program. Kidneys from five cadaveric donors were transplanted in pairs to ten recipients with a difference in cold ischemia time (CIT) of >4 h, and grouped according to CIT (group 1: patients that underwent transplantation first; group 2: patients that underwent transplantation second). CIT was shorter (5.5+/-2.0 h vs. 11.7+/-3.1 h, P<0.01), and the first day diuresis was higher (287.4 ml/h vs. 134.8 ml/h, P<0.05) in group 1 than in group 2. No patient in group 1 required dialysis, 3/5 patients in group 2. Rejection episodes occured more often in group 2 (5/5 vs. 3/5), and the hospital stay tended to be shorter in group 1 (33.0 days (27-43) vs. 54.2 days (27-112)). Our study confirms the positive effect of ultra-short CIT on early graft function in marginal donors, despite overall short CIT. The increase in delayed graft function (DGF) may lead to an extended hospital stay and dialysis requirements. Efforts to realize simultaneous transplantation in two recipients seem necessary to optimize results.