Abdominal aortic aneurysm repair after pancreaticoduodenectomy

We present two cases of patients with coincidental pancreatic disease and abdominal aortic aneurysm. Initial pancreaticoduodenectomy was followed by staged abdominal aortic aneurysm repair via a retroperitoneal approach in both cases. We recommend the retroperitoneal approach over the transperitoneal approach as an easier and safer method of aortic aneurysmorrhaphy after the Whipple procedure.

Cryopreservation of pig and human liver slices

The ability to cryopreserve human liver slices would greatly enhance the opportunities to test potentially hepatotoxic drugs and environmental contaminants as well as the metabolism of these compounds. This study focused on trying to cryopreserve pig and human liver slices. Since the acquisition of human liver tissue is unpredictable and scarce, an animal model was sought to predict problems associated with cryopreservation of human tissue. The pig liver was chosen because of its anatomical and physiological resemblance to human liver. The human liver tissues that did become available were obtained through the Arizona Organ Bank and the National Disease Research Interchange and from surgical liver resections. An in vitro culture system that employed precision-cut liver slices was used in this study. Different types and concentrations of cryoprotectants, cooling rates, and culture media were all tried in an attempt to cryopreserve pig and human liver slices. The viabilities of fresh and cryopreserved liver slices were evaluated using slice K+ retention and protein synthesis. Pig liver slices following cryopreservation retained between 80 and 85% of intracellular K+ content and protein synthesis as compared to controls using 1.4 M Me2SO, a 12 degrees C/min cooling rate, and a rapid rewarming rate of direct submersion of the slice into 37 degrees C fetal calf serum. Human liver slices following cryopreservation retained between 54 and 89% of intracellular K+ content and protein synthesis as compared to controls using the same protocol as for pigs, except that lower cooling rates were giving better results. The large variation seen in cryopreserved human liver slices was due to the length of warm and cold ischemia to which the tissue was exposed before arriving at the laboratory. This study indicated that pig and human liver slices can be cryopreserved and used for future toxicological and metabolic studies.

Cocaine hepatotoxicity in cultured liver slices: a species comparison

Studies were carried out in order to find a sensitive in vitro model with which to investigate cocaine-mediated hepatotoxicity. Precision-cut liver slices were prepared from: human, domestic pig, New Zealand white rabbit, Sprague-Dawley (S/D) rat, and two mouse strains (DBA/2Ha and ICR). The rationale for the choice of these species was that information on in vivo effects of cocaine was available in the literature. Slices were cultured for up to 6 h in the presence of 0-5 mM cocaine. Indices of toxicity consisted of K+ retention and Ca2+ uptake. Minimal effects and no clear dose-response relationships were observed. In addition to the studies with non-pretreated animals, liver slices were prepared from DBA/2Ha and ICR mice, both induced by housing on pine shavings, and phenobarbital pretreated Sprague-Dawley rats. The induced ICR mouse and rat were approximately 3 times more sensitive to cocaine-mediated hepatotoxicity. The following order of sensitivity to cocaine-mediated hepatotoxicity was established: induced rat = induced ICR mouse much greater than induced DBA/2Ha mouse = rabbit = uninduced ICR mouse = uninduced DBA/2Ha mouse = uninduced rat greater than pig = human.

Regression of perineurial cell basement membrane in a human diabetic following isogenic pancreas transplant

Perineurial cell basement membrane (PCBM) thickening is a consistent feature in diabetes mellitus (DM) and may have relevance to the cause of DM neuropathy. In this ultrastructural morphometric study of identical twins discordant for DM, we found that the PCBM was significantly thicker in the dermal nerves of the diabetic twin. Following pancreas transplantation (PT) and a 2-year period of euglycemia, the PCBM in both dermal and sural nerves was significantly thinner. At the end of the 2nd year post-PT, the PCBM thickness in the dermal nerves of the diabetic was not significantly different from the non-DM twin. The correction of diabetic dysmetabolism may have played a role in the regression of PCBM. These data suggest that PCBM thickening may not be a permanent legacy of DM.

Rhabdomyosarcoma of the biliary tree: the case for aggressive surgery

Embryonal rhabdomyosarcoma of the bile ducts is associated with a poor prognosis because complete resection rarely is considered possible. We reviewed the literature and report our experience with the management of 3 consecutive patients. The patients were 1, 4, and 9 yr old at presentation, and had jaundice, cachexia, and an abdominal mass. The tumor arose in the common hepatic duct in 2 patients, and in the left hepatic duct in the other. All had tumor extension into both lobes of the liver and residual disease was noted after resection. Two patients were given tumor bed irradiation and all received multiple-drug chemotherapy. Two patients are alive, jaundice free, and with no evidence of disease at 9 mo and 14 yr follow-up. The other patient was a long-term survivor, but developed local recurrent tumor after cessation of chemotherapy and expired 33 mo after diagnosis. The traditional anatomic criteria of hepatic tumor resectability may not apply to botryoid sarcoma of the bile ducts. Aggressive surgery combined with the new adjuvant therapies appears to provide the best chance for a longer survival.

Communication of intrahepatic cavities with bile ducts: demonstration with Tc-99m-diethyl-IDA imaging

Tc-99m-diethyl-IDA imaging demonstrated intrahepatic bile leaks in two patients. The first patient had an intrahepatic abscess associated with a common bile duct stone; he was successfully treated with common duct lithotomy and antibiotics, but without surgical drainage of the intrahepatic abscess. The second patient had bile leakage into an intrahepatic cavitary hematoma after abdominal trauma.

Relative role of Tc-99m-diethyl-IDA and Tc-99m-sulfur colloid in the evaluation of liver function

Imaging of diffuse liver disease is traditionally done with Tc-99m-sulfur colloid. The advent of Tc-99m-labeled hepatobiliary agents led the authors to reevaluate the role of Tc-99m-sulfur colloid. A total of 95 paired Tc-99m-diethyl-IDA and Tc-99m-sulfur colloid studies were performed in 61 patients (60 paired studies in liver transplant patients and 35 paired studies patients who had not received liver transplants). The following parameters were visually graded on a five-point scale: Tc-99m-diethyl-IDA clearance and time of appearance of appearance of intestinal activity; and Tc-99m-sulfur colloid liver size, bone marrow activity, splenic size, splenic activity, lung activity. Total serum bilirubin levels were used as the standard measure of liver function. The Tc-99m-diethyl-IDA parameters correlated more highly with total serum bilirubin than did the Tc-99m-sulfur colloid parameters in both the transplant and nontransplant groups. In conclusion, Tc-99m-diethyl-IDA appears to be the preferred radiopharmaceutical for evaluation of hepatocellular function, although both agents may be needed in certain clinical situations.

The technique of prolonged thoracic duct drainage in transplantation

Prolonged thoracic duct drainage as an immunosuppressive adjunct was accomplished in 96 per cent of organ recipients upon whom it was attempted.

Excisional treatment of cavernous hemangioma of the liver

Fifteen patients had hepatic hemangiomas removed with liver resections that ranged in extent from local excision to right trisegmentectomy. There was no mortality and little morbidity. The propriety and feasibility of extirpative treatment of such liver tumors has been emphasized by this experience.

The use of cyclosporin A and prednisone in cadaver kidney transplantation

Eighteen patients were treated with primary cadaveric renal transplantation using cyclosporin A therapy, and four more patients undersent cadaveric retransplantation. Eleven of the 22 recipients were conditioned with lymphoid depletion before transplantation, using thoracic duct drainage or lymphapheresis for two to eight and one-half weeks. Cyclosporin A was begun a few hours before grafting. The other 11 patients were pretreated with cyclosporin A for from one day to 18 days. After transplantation, the majority of patients in both subgroups of 11 had rejection develop, but in most, the immunologic process was readily controlled with relatively small dosages of prednisone. After follow-up periods of two to four and one-half months, one patient has died of the complications of a coronary artery reconstruction that was not related to the transplantation. Another graft was lost from rejection, and a third organ was removed because of ureteral necrosis. Nineteen of the original 22 cadaveric kidneys are functioning, including 17 of the 18 kidneys given to patients who were undergoing transplantation for the first time. The only loss in the latter group of 18 patients was in the patient who died after an open heart operation. Results of these studies have shown that cyclosporin A is a superior and safe immunosuppressive drug but that, for optimal use in cadaveric transplantation, it usually should not be given alone. Steroid therapy greatly amplified the value of cyclosporin A. Unless major delayed morbidity develops which is not obvious so far, this drug combination should permit revolutionary advances in the transplantation of all organs. Other adjuncts to the cyclosporin A-steroid combination, including lymphoid depletion techniques, will require further investigation.

Renal isotransplantation without immunosuppression

Four renal isografts have been performed and all have had satisfactory function for 7 1/2 to 17 2/3 years without prophylactic or therapeutic immunosuppression. Three of these patients originally had glomerulonephritis, and in one there was histologic evidence of recurrent disease, 7 1/2 years after transplantation, without proteinura and without change in renal function. Although this experience is small, it suggests that prophylactic immunosuppression is not appropriate for recipients of renal isografts.

Common bile duct obstruction and cholangiohepatitis in clonorchiasis

This report describes a patient with common bile duct obstruction and cholangiohepatitis. Patients with clonorchiasis are usually asymptomatic and treatment is limited to complications. Treatment consists of cholecystectomy, choledochotomy, and T-tube drainage. A bypass procedure is indicated in cases of heavy infestation and recurrent disease.

Right trisegmentectomy for hepatic neoplasms

Thirty patients had right trisegmentectomy for 19 primary hepatic malignant tumors, seven localized liver metastases and four benign lesions. A technical refinement that aided resection of bulky posterior and superior tumors was intrahepatic identification and control of the right hepatic vein. The operative mortality was 3.3 per cent. Late hepatic insufficiency was not observed. More than one-half of the patients operated upon a year or more ago for primary hepatic malignant growths had a tumor-free state at the 12 month follow-up period. Beyond this time, there was only one recurrence. The results in children were twice as good as in adults. The results in treating localized liver metastases from distant primary sites were inferior to those in treating primary hepatic tumors. A hypothetical case was made for combining hepatic resection with adjuvant chemotherapy, even though our experience could not be construed as direct support for this practice.

Liver transplantation for advanced liver disease with alpha-1-antitrypsin deficiency

Alpha-1-antitrypsin deficiency associated with chronic obstructive airway disease was recognized in 1963 by Laurell and Ericksson.1 In 1969, Sharp2 described the first cases of alpha-1-antitrypsin-deficiency disease in children with cirrhosis. Since then, this inborn error has been recognized as one of the more common factors in cirrhosis of infancy and childhood,3 including “neonatal hepatitis.”4 Alpha-1-antitrypsin is a glycoprotein that accounts for a major portion of the alpha-1 globulin fraction of the serum.5 It is responsible for approximately 90 per cent of the antitrypsin activity6 of the serum, and it also inhibits several other plasma enzymes, including plasmin,7 elastase,8 collagenase,9 and chymotrypsin.10

Cirrhosis develops in about 15 per cent of patients with homozygous phenotype PiZZ (Pi = protease inhibitor),11 and there have been a few recent reports of cirrhosis in heterozygous patients.12 ,13 There has been no effective, specific medical treatment for such patients. This report will examine the place of orthotopic liver transplantation in the treatment of seven white patients who had end-stage liver disease due to alpha-1-antitrypsin deficiency. After transplantation, the phenotypes of the recipients became those of the donors, and alpha-1-antitrypsin levels were restored to normal. Thus, the metabolic basis of the disease was corrected for as long as the patients survived the transplantation procedure. Three of the patients are still alive after 13, 21, and 36 months. The others died between 12 days and 28 months after transplantation.

Clinical comparison of 99mTc-diethyl-IDA and 99mTc-PIPIDA for evaluation of the hepatobiliary system

Fifteen patients with a wide range of hepatobiliary function were studied with both 99mTc-diethyl-IDA and 99mTc-PIPIDA. In images obtained 5 to 60 minutes after injection, 99mTc-diethyl-IDA was clearly superior with respect to liver/background, hepatic ducts/liver, and small bowel/background ratios. The 99mTc-diethyl-IDA transit time from blood to small intestine averaged 12.2 minutes less than that of 99mTc-PIPIDA. Quantification of relative hepatocyte extraction efficiency indicated that it was 2.15 times higher for 99mTc-diethyl-IDA. Cumulative 3-hour urine collections following injection demonstrated increasing renal excretion of 99mTc-PIPIDA with rising total serum bilirubin levels in a manner quantitatively similar to that determined previously for 99mTc-diethyl-IDA. The authors conclude that 99mTc-diethyl-IDA is superior to 99mTc-PIPIDA for studies of the hepatobiliary system.

Thoracic duct drainage before and after cadaveric kidney transplantation

Twenty-seven consecutive recipients of cadaveric kidneys, including five with pre-existing warm cytotoxic antibodies, were treated with thoracic duct drainage before and after transplantation. Fourteen patients who had lymph drainage for 26 to 58 days before transplantation had minor cytotoxic antibody responses after grafting, even if the antibodies had been present before therapy. Only one of the 14 recipients had any rejection during the follow-up periods of one to six months. There were two deaths. The 13 patients pretreated for 17 to 23 days exhibited stronger cytotoxic antibody responsiveness, and five of these recipients had significant rejections of which four were reversible. One of the latter 13 patients died. These clinical and immunologic studies have established the value and have defined the appropriate timing of preoperative thoracic duct drainage in kidney transplantation. They have also directed attention to the rationale andthe probable value of using other immunosuppressive methods for preparatory host conditioning instead of beginning such therapy at the time of transplantation.

Thoracic duct fistula and renal transplantation

Thoracic duct drainage (TDD) was established for 21-115 days in 40 kidney recipients with an average removal per patient day of 4.7 1 lymph and 1.88 billion cells. Cellular and humoral immunity were depressed. TDD and immunosuppressive drugs were started at transplantation in 35 recipients of cross-match negative grafts. Although the results were better than in precedent non-TDD controls, eight patients rejected their grafts before a full TDD effect, and three of the eight developed predominantly anti-B lymphocyte cytotoxic antibodies which were probably responsible for positive cross-matches with their next donors. With continuing TDD, all eight patients had good initial function after early retransplantation. In five more "nontransplantable" patients with performed cytotoxic antibodies, TDD was started 30-56 days before transplantation. In these five pretreated patients, antibodies persisted with positive antidonor cross-matches. Hyperacute rejection occurred repeatedly in two patients with high anti-T (and anti-B) titers, but was surmounted in three patients with lower titers. From the clinical and immunologic data, we have concluded that TDD should be used for pretreatment of all cases with or without prior antibodies, and have suggested an adjustable management plan that takes into account new developments in antibody monitoring.

Fifteen years of clinical liver transplantation

Liver transplantation in humans was first attempted more than 15 yr ago. The 1-yr survival has slowly improved until it has now reached about 50%. In our experience, 46 patients have lived for at least 1 yr, with the longest survival being 9 yr. The high acute mortality in early trials was due in many cases to technical and management errors and to the use of damaged organs. With elimination of such factors, survival increased. Further improvements will depend upon better immunosuppression. Orthotopic liver transplantation (liver replacement) is the preferred operation in most cases, but placement of an extra liver (auxiliary transplantation) may have a role under special circumstances.

Liver replacement for pediatric patients

Between March 1963 and January 1978, 74 patients 18 years of age or younger have had liver replacements at the University of Colorado Medical Center, Denver. The most common cause of native liver failure was biliary atresis (48/74, 65%); the second most common cause was chronic aggressive hepatitis (12/74, 16%). Twenty-nine patients (39%) lived for at least one year, and 16 are still alive one to nine years after transplantation. Technical surgical problems, rejection, and infection were the main causes of death. Improved immunosuppression is needed; nevertheless, the quality of life in the long-term survivors has encouraged continuation of this difficult work.

Liver transplantation

This assessment of the role of liver transplantation in treating end-stage liver disease today is based on two major series, one from Denver and the other from the Cambridge/Kings College Hospital, England. The findings of these groups are highlighted, as are the changes in technique that have led to considerably improved survival in the past two years.

Liver transplantation--1978

The development of liver transplantation has been made difficult because of the enormous technical difficulties of the procedure and because the postoperative management in early cases was defective in many instances. With surgical and medical improvements, the prospects for success have markedly increased recently. The wider use of thoracic duct fistula as an adjuvant measure during the first 1 or 2 postoperative months is being explored.

The quality of life after liver transplantation

The quality of life after liver transplantation ranges from poor to superior. The social and vocational outcome is dependent on the quality of homograft function and on the steroid doses necessary to maintain function. A good long-term prognosis is usually evident by 1 year postoperatively. The complete rehabilitation of so many patients has encouraged us to continue our efforts in this difficult field.

Gastrointestinal complications of hepatic transplantation

In this series of 150 orthotopic hepatic transplants, clinically significant gastrointestinal hemorrhage occurred in 34 patients (23%). Five patients (15%) survived this complication. Enteric perforations occurred in 20 patients following 198 biliary-enteric procedures. Only one patient survived. Enteric perforations unrelated to biliary procedures fared only slightly better with one survivor among eight perforations. These results clearly do not warrant complacency. Modifications advocated are an aggressive diagnostic approach and early reoperation with establishment of extensive peritoneal drainage where necessary.

A clinical comparison of 99mTc-diethyl-iminodiacetic acid, 99mTc-pyridoxylideneglutamate, and 131I-rose bengal in liver transplant patients

The relative merits of three radiopharmaceuticals for evaluating liver transplant patients were determined in paired studies. In 86% of studies both 131I-RB and 99mTc-PG gave similar information for differentiation of hepatocellular disease and billary tract obstruction. 99mTc-PG probably demonstrates the biliary tract and small intestine better early after injection (8%); 131I-RB is probably better in showing the colon at 24 hours when intestinal activity is not seen by 1 hour (6%). 99mTc-diethyl-IDA is superior in all respects when compared to 99mTc-PG. The blood retention method (20 min./5 min.) showed that none of the radiopharmaceuticals was a reliable indicator of hepatocyte function when compared to total serum bilirubin.

Liver resection for hepatic adenoma

Between 1970 and 1978, eight hepatic adenomas were resected. Four of the eight patients took oral contraceptive pills before the hepatic adenoma was identified; one patient was male. Four patients had evidence of bleeding at the time of presentation. The original histologic diagnosis in the first five patients was malignant hepatoma. There has been no known recurrence of tumor and all patients are well. The use of oral contraceptives in these patients has been prohibited. Formal anatomic resection is recommended for hepatic adenoma when this procedure can be done without mortality or serious morbidity; however, in the future, less drastic treatments, such as occlusion of the hepatic arterial circulation to the tumor or discontinuation of oral contraceptives, may prove as effective as tumor resection.

Homotransplantation of the liver in a patient with hepatoma and hereditary tyrosinemia

A girl with hereditary tyrosinemia, diagnosed at 6 months of age, was treated with a diet restricted in phenylalanine and tyrosine. At 9 1/2 years of age she developed an acutely enlarged liver and spleen, and the diagnosis of hepatocarcinoma was made. The patient received a liver transplant and tyrosine metabolites became normal while she was receiving a regular diet. Three months later, an infected thrombosis of the portal vein caused her death. Liver transplant appears to be an effective method of enzyme replacement in tyrosinemia and should be considered for prevention of hepatoma.

Acute neurological complications after liver transplantation with particular reference to intraoperative cerebral air embolus

Nine of 48 adult patients who underwent orthotopic liver transplantation developed significant clinical neurological abnormalities recognized shortly after operation. Decrease in consciousness occurred with resultant coma, focal and generalized seizures and the occasional appearance of a state of akinetic mutism. Neuropathological abnormalities consisted of multifocal areas of infarction in cerebral cortex and basal ganglia in five patients, central pontine myelinolysis in five (often more extensive than usually reported), Wernicke's encephalopathy in three, glial nodules in two, and fungal abscesses in one. Alzheimer II astrocytosis was found in all brains available for retrospective study. There was direct evidence in two of the patients that air embolization from the homografts had occurred. Correlation of this with the brain infarcts in these and other cases seems reasonable. The ease with which air passed to the systemic circulation is explicable by the right to left venous--arterial shunts that are common in chronic liver disease. With the delination of this cause for the neurologic complications, measures to prevent it in future cases have been described.

Portacaval shunt and hyperlipidemia

The use of a completely diverting portacaval shunt for the purpose of lowering the serum concentration of cholesterol and low-density lipoproteins is reviewed and a recommendation provided that such a shunt for hyperlipidemia should be considered for type II individuals.

Canine and human liver preservation for 6 to 18 hr by cold infusion

Forty-one dog livers were preserved with cold, lactated Ringer's, plasma, or intracellular (Collins) solutions. Consistent survival was obtained with all three solutions for 9 hr. After 18 hr, the plasma and Collins solutions permitted survival, with the Collins solution having a slight overall advantage. The method using Collins solution has been used to preserve seven human livers in Los Angeles, to transport the organs to Denver, and to transport them as orthotopic grafts from 6 hr, 45 min to 10 hr later.