C4d: a marker for hepatic transplant rejection

BACKGROUND

Acute rejection is still a common complication of hepatic transplantation. The diagnosis, based on the histological examination of the graft, may be difficult to confirm in the setting of combined hepatitis C virus infection. The presence of C4d in the portal capillaries could facilitate differentiation between acute rejection and relapsed hepatitis C. The deposit of C4d provides evidence of activation of humoral immunity. To attempt to confirm this hypothesis, we searched for the presence of C4d in posttransplant hepatic biopsies.

METHODS

Thirty-six biopsies from 34 patients were analyzed retrospectively. The samples had been requested for one of the following reasons: suspected rejection, relapsed hepatitis C infection, or systematic check-up 1 year after the transplant.

RESULTS

C4d expression was common in biopsies classified as acute rejection (33%) and chronic rejection (100%). C4d was never detected in the event of recurrent hepatitis C infection without rejection.

CONCLUSION

These results, which are comparable to recently published data, give credence to the theory that C4d could be used as a marker for rejection following hepatic transplantation.

Improved Liver Function and Decreased Hepatitis C Viral Load After Tacrolimus Was Replaced by Cyclosporine

Potential antiviral properties of cyclosporine against hepatitis C virus have been highlighted in several publications. Therefore, we investigated the effect of a switch from tacrolimus to cyclosporine in a liver transplant recipient with recurrent hepatitis C who did not respond to antiviral therapy. The patient received a liver transplant for hepatitis C cirrhosis. Initial immunosuppressive treatment was based on tacrolimus. Because of viral activity, a combined therapy was initiated 20 months later including interferon and ribavirine. Then, due to a lack of virological and biochemical response, tacrolimus was replaced by cyclosporine (Neoral), while maintaining the same antiviral therapy. Decreases in the viral load and transaminases levels were observed.

Adult-to-Adult Living Related Liver Transplantation: Preliminary Results of the Hepatic Transplantation Group in Algiers

INTRODUCTION

In the absence of cadaveric grafts, a living donor liver transplant program was started in Algeria in February 2003. The aim of this study is to report the preliminary results.

PATIENTS AND METHODS

From February 2003 to September 2004, eight adult-to-adult living related liver transplantations were performed. The donors were six women and two men of mean age of 25 years (range, 18 to 48 years). Right hepatectomy was performed in seven patients and left hepatectomy in one patient. The recipients were four women and four men of mean age 33 years (range, 16 to 56 years). Follow-up ranged from 1 month to 18 months (median 7 months).

RESULTS

All donors survived the procedure. In the immediate postoperative period, two donors experienced complications. One donor underwent reoperation for hemorrhage and one suffered partial portal vein thrombosis, which was treated medically. The eight donors are alive at home without any late complications. One recipient died on postoperative day 43 due to sepsis. Among the seven other recipients, two experienced complications: one bilioma in relation to a biliary-intestinal fistula and one thrombosis of the splenic vein with a left portal embolus. At present the seven recipients are alive with normal liver function and without complications.

CONCLUSION

Our results are comparable to other reports suggesting that adult-to-adult living related liver transplantation is feasible with no mortality and low morbidity in donors. However, it is important to develop a cadaveric liver transplant program.

[Roux-en-Y limb anastomosed to small biliary duct]

We describe a simple and safe technique of cholédocho-jejunostomy using a Roux-en-Y jéjunal limb, to repair immediately biliary tract injuries, even when the conduits are thin.

[Two tapes to control the main fissure of the liver]

Herein we report a technique that allows a rapid and selective clamping of the left and right glissonian sheats and that secures the opening of the main fissure. The posterior face of segment IV capsula is opened immediately above the hilum on the left side of the gallbladder fossa. The tip of a right angled dissector is gently pushed in the liver substance from front to back while maintained against the hilar plate, until it arises in the caudate process just below the pedicle. A tape is used to encircle the Glisson sheath. Its inferior extremity can be picked up either on the right or the left side of the liver pedicle in order to clamp the right or the left portal pedicle, respectively. Both clamping precisely mark the anterior limit of the main fissure. Using a Kelly forceps, a second tape is introduced in the Couinaud space, between the inferior vena cava and segment one. The inferior extremity of this tape is then picked up above the Glisson sheat and allows to hang the posterior limit of the main fissure which can be securely approached. The two tapes technique cannot be applied when liver is fibrotic or when biliary ducts are dilated.

Surgical complications and treatment during resection for malignancy of the high bile duct

From January 1968 to January 1997 a series of 50 of 109 patients had undergone resection for high bile duct cancer in our institution in Rennes, France. The overall operative mortality was 12%, but there were no deaths among those who had only tumor resection or those with hepatectomy with vascular reconstruction. The early complications were biliary fistula (four cases) and subphrenic abscess (three cases), of which two of the biliary fistulas resulted in mortality. There were three gastrointestinal hemorrhages; one was due to gastritis related to hepatorenal insufficiency and was fatal. Two other deaths were due to respiratory failure and ascites associated with hepatic insufficiency. In one patient after liver transplantation with cluster resection, a biliary leak and ileocolic fistula were the cause of postoperative mortality. Another patient suffered a ruptured mycotic aneurysm after pretransplant transtumoral intubation, which emphasizes the risk of infection in an immunosuppressed patient. The main late complication was cholangitis (8 cases). This complication is most often a symptom of recurrence (four cases). Some are due to benign causes (intrahepatic lithiasis, intrahepatic foreign body granuloma). Surgical exploration is mandatory to exclude benign complications, which can then be treated palliatively. Four patients presented with recurrence but without cholangitis. In conclusion, the causes of complications after resection of high bile duct cancer should be carefully assessed to choose the correct treatment. Late cholangitis is a symptom of recurrence, but it should be explored and managed precisely.

Proximal bile duct cancer: high resectability rate and 5-year survival

OBJECTIVE

To review and update the authors' experience with resectional surgery for proximal bile duct carcinoma (Klatskin tumor) and assess the role of liver resection over the past 25 years.

BACKGROUND

Until recently, resection of proximal bile duct carcinoma was uncommon, with most patients undergoing palliative procedures. The authors adopted a radical surgical approach aimed at definitive cure in 1974. Recent reports suggest that resection improves outcome.

METHODS

The records of 40 of 94 patients (23 men, 17 women, age range 34-81 years) diagnosed with proximal bile duct carcinoma who underwent resection between 1968 and 1993 were reviewed. According to the Bismuth classification, there were five type I, four type II, 25 type III, and six type IV lesions; 11 patients underwent tumor resection alone, and 25 patients had combined tumor and liver resection (seven of these also underwent an associated regional vascular resection). In 3 patients, venous allografts were harvested from cadaveric donors and used to reconstruct the portal vein. Four patients underwent liver transplantation; in two, organ cluster-type resections including the liver with porta hepatitis and pancreas were performed.

RESULTS

The resectability rate in the more recent period of the study was 49.4%. Most type I, three (of four) type II, T in situ, T1a, T1b, and all stage 0 tumors were resected without hepatectomy. In the other subgroups of tumors, the main surgical procedure was hepatectomy. Thirty-day mortality was 12.5%. After tumor resection alone, survival at 1, 3, and 5 years was 81.8%, 45.5%, and 27.3%, respectively. After tumor resection and hepatectomy without vascular resection, 1-, 3-, and 5-year survival was 66.7%, 16.7%, and 6%, respectively. With vascular resection, survival rates were similar: 64%, 20%, and 4%, respectively.

CONCLUSION

The type of surgery required to achieve cure is closely related to tumor location, TNM classification, and staging. Increasing resectability through the use of hepatectomy improves survival and offers a chance of cure in patients with more advanced disease.

Gastric bypass for malignant esophagotracheal fistula: a series of 21 cases

OBJECTIVE

Patients with cancer of the esophagus who develop an esophagotracheal fistula die within 1 month in dramatic conditions of malnutrition and asphyxia. We assessed the beneficial palliative effect of the Kirschner operation in the treatment of esophagotracheal fistula.

METHODS

Between January 1980 and August 1995, 21 patients among a continuous series of 847 with cancer of the esophagus developed an esophagotracheal fistula. Prior to surgery, 2 patients had an esophageal prosthesis followed by radio- and/or radiochemotherapy and 6 had radio- and/or chemotherapy at curative doses. The Kirschner operation was carried out in all patients with exclusion of the lower end of the esophagus using a Roux-en Y-loop (n = 19) or ligature (n = 2).

RESULTS

Within 1 month of surgery, 8 patients (38%) died. Median length of stay in the intensive care unit and hospitalization was 6 days (1-30) and 17 days (3-57), respectively. Among the 13 survivors, pulmonary infections (n = 2) and cervical fistulae (n = 5) complicated the postoperative period. Among the cervical fistula, 3 of them resolved favorably. Radio- and/or chemotherapy was given postoperatively in 7 patients without any improvement in survival. Among the 13 patients surviving beyond the postoperative period, median survival was 109 days; 7 were able to resume oral nutrition and quality of life was assessed as excellent in 6 of them.

CONCLUSION

The Kirschner operation can provide a beneficial palliative effect in patients with an esophagotracheal fistula despite the high risk of operative mortality. Ideally, the Kirschner should be carried out in young patients who are still in good general health, before the development of respiratory complications compromises surgery.

["De novo" cancer after organ transplantation]

From March 1972 to 1st of January 1996, 804 kidney, liver and pancreas transplants were performed in 690 patients. 39 post transplant cancers occurred in 27 patients. 21 skin tumors (15 squamous cell carcinoma, 4 basocellular carcinomas, 1 squamous carcinoma, 1 melanoma), 4 squamous cancers (anus, esophagus, tongue, and parotid), 4 post-transplant lymphoproliferative disorders, 1 non-Hodgkin's lymphoma T, 4 gynecological tumors (breast, ovarian peritoneal carcinomatosis, 2 uterine cervix cancers), 4 miscellaneous tumors (larynx, right colon, brain, prostate, own kidney). 14 patients died (14/27: 52%). Post transplant de novo cancers are a major risk in transplant patients These cancers are mainly represented by skin tumors and lymphomas. Skin cancers are mainly spinocellular and occur in the areas which are exposed to the sun. Post transplant lymphoproliferative disorders are very close to Burkitt's lymphoma, they produced B lymphocyte proliferation due to the reduction of the control of T lymphocytes and induced by Epstein-Barr virus. They can disappear with the diminution of immunosuppression.

Experimental colonic carcinogenesis: a new animal model

The aim of this work was to develop an animal model of accessible colonic tumours simulating human carcinogenesis. A segment of the colon was exteriorized to the skin in 60 rats and swabbed with N-methyl-N-nitrosourea. All the animals developed tumoral abnormalities or frank dysplasic tissue 7 months after the beginning of the experiment. This animal model which closely mimics human colonic carcinogenesis is particularly interesting because tumour development can be monitored in live animals without interrupting normal intestinal functions.

[200 first hepatic transplantation at the Rennes University Hospital]

From 21st of april 1978 to 1st september 1994, 200 liver transplantations in 172 patients were performed in the Medical Center of University of Rennes. Three patients had a liver and kidney transplant. 26 patients received a second transplant (13%) and 2 patients a third transplant (1%). There were 110 males and 62 females with a mean age of 43.7 years (range 17 months-66 years). The indications of transplantations were the following: 22 fulminant hepatitis (12%), 104 cirrhosis (60.5%), including 41 alcoholic cirrhosis (24%), 21 post-hepatitis B cirrhosis (12.2%), 24 post-hepatitis C cirrhosis (14%), 6 autoimmune cirrhosis, 7 primary biliary cirrhosis (4%), 21 non A non B cirrhosis (12.9%), 3 undetermined cirrhosis. Thirty one patients had a liver transplantation for cancer. The other indications were 5 sclerosing cholangitis and 2 atresia of the biliary tract. 45% of the patients had an uneventful postoperative course. In hospital mortality rate is related to the indication and Child Pugh classification in cirrhotic patients. The vascular surgical complications were 8.5%, biliary complications 6.1%, intra-abdominal infection 9.2%, intra-abdominal bleeding 5.5%. The rate of reoperation was 18.5%. 23 re-transplantations were performed in emergency and 6 electively (one from outside). The overall survival of patients from 1978 to 1994, including the patients before cyclosporine era, the use of extracorporeal circulation, the preservation with Wisconsin solutions and with main indications for cancer was 69% at 1 year and 59% at 5 years. After 1988, the overall patient survival was 75% at 1 year and 70% at 5 years. The graft and patient survival is mainly related to the indications. In fulminant and subfulminant hepatitis, the quality of the graft was preferred as often as possible. The actuarial graft survival at 1 year, 3 years and 5 years was respectively 75%, 70.45% and 70.45%. The actuarial patient survival was 77.3%, 72.5% and 72.5%. In liver transplantation for cancer, the actuarial patient survival at 1 year, 3 years and 5 years is respectively 55%, 32% and 23.5%. 5 patients are alive and well at 5 years, including a patient who underwent a Cluster operation for Klatskin tumor. In post-hepatitis cirrhosis, the patient actuarial survival at 1 year, 3 years and 5 years was 79%, 76.5% and 76.5% and in alcoholic cirrhosis 75%, 72% and 72%. The actuarial survival is closely related to Child Pugh Classification (at one year Child A 87%, Child B 72.4%, Child C 58%).

CONCLUSION

in this series of the first 200 liver transplants at the University of Rennes Medical Center, graft and patient survival depends on the evolution of the surgical technic but it is also closely related to the indication. In fulminant hepatitis, the quality of the graft (without incompatible graft, if possible) should permit to avoid retransplantation and to obtain results closely to the elective transplantation. Liver transplantation for cancer should be restricted. In cirrhosis, results are depending upon Child Pugh classification. The conclusions of Paris consensus conference should be followed. The limited number of donor livers call for the "priorization" (T.E. Starzl) favoring those patients who will benefit most, i.e., patients with the most serious conditions and the poorest short term vital prognosis.