Buruli ulcer in a traveller returning from Madagascar: the first report of Mycobacterium ulcerans infection from the region

We describe a case of Buruli ulcer diagnosed by tissue culture and PCR in a Caucasian male returning from Madagascar where he served as a health-care worker in the Antsiranana region.

To the best of our knowledge, this could be the first case of Mycobacterium ulcerans infection reported in Madagascar.

Anogenital distance is associated with genital measures and seminal parameters but not anthropometrics in a large cohort of young adult men

STUDY QUESTION

Is the anogenital distance (AGD) correlated to anthropometric, genital and sperm parameters in young adult men?

SUMMARY ANSWER

We observed that reduced AGD is strongly associated with altered semen parameters and reduced testicular volume.

WHAT IS KNOWN ALREADY

Abnormalities in the foetal development of the testis have been suggested as causative of common male reproductive disorders, such as cryptorchidism, hypospadias, reduced semen quality and testicular germ cell tumour, collectively defined as 'testicular dysgenesis syndrome'. In human epidemiological studies, alterations in AGD have been frequently associated with clinically relevant outcomes of reproductive health, suggesting AGD as a marker of foetal testicular development.

STUDY DESIGN, SIZE, DURATION

This study was performed within the annual screening protocol to evaluate male reproductive health in the high schools of Padua and surroundings (Veneto Region, the North-East of Italy). Here we report the findings of 794 subjects who completed the study protocol between October 2016 and May 2017.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We evaluated 794 students aged 18-19 years recording the following parameters: height, weight, BMI, waist circumference, arm span, pubis-to-floor and crown-to-pubis length, penile length and circumference, testicular volumes, semen parameters and AGD (measured from the posterior base of the scrotum to the centre of the anus).

MAIN RESULTS AND THE ROLE OF CHANCE

Of the subjects, 49% had an abnormal arm span-height difference (>3 cm) and 63.4% had an altered ratio of crown-to-pubis/pubis-to-floor length (≤0.92). The rate of subjects with reduced testicular volume was 23%. Median sperm concentration was 51.0× 106/ml and total sperm count was 122.5 × 106. AGD showed a direct positive relation with testicular volume and penile length and circumference (R = 0.265, 0.176 and 0.095, respectively, all P < 0.05). No significant relation was observed between AGD and anthropometric parameters. Sperm concentration, total sperm count, progressive motility and normal morphology showed a significant and positive correlation with AGD (R = 0.205, 0.210, 0.216 and 0.117, respectively, all P < 0.05).

LIMITATIONS, REASONS FOR CAUTION

Our cohort of young adults is not representative of the general population. Hormonal evaluation was missing.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings show that AGD is associated with testicular volumes, penile measures and seminal parameters in young adult men. Because AGD is hormonally determined during foetal life, the reported high incidence of reduced semen quality and reduced testicular volume could be related to a reduced androgenic exposure in utero. AGD could represent a simple and useful method to evaluate testicular and penile development in adult men.

STUDY FUNDING/COMPETING INTEREST(S)

The authors have no potential conflict of interest to declare. No external funding was obtained for this study.

TRIAL REGISTRATION NUMBER

N/A.

Endocrine Disruption of Androgenic Activity by Perfluoroalkyl Substances: Clinical and Experimental Evidence

BACKGROUND

Considerable attention has been paid to perfluoroalkyl compounds (PFCs) because of their worldwide presence in humans, wildlife, and environment. A wide variety of toxicological effects is well supported in animals, including testicular toxicity and male infertility. For these reasons, the understanding of epidemiological associations and of the molecular mechanisms involved in the endocrine-disrupting properties of PFCs on human reproductive health is a major concern.

OBJECTIVE

To investigate the relationship between PFC exposure and male reproductive health.

DESIGN

This study was performed within a screening protocol to evaluate male reproductive health in high schools.

PATIENTS

This is a cross-sectional study on 212 exposed males from the Veneto region, one of the four areas worldwide heavily polluted with PFCs, and 171 nonexposed controls.

MAIN OUTCOME MEASURES

Anthropometrics, seminal parameters, and sex hormones were measured in young males from exposed areas compared with age-matched controls. We also performed biochemical studies in established experimental models.

RESULTS

We found that increased levels of PFCs in plasma and seminal fluid positively correlate with circulating testosterone (T) and with a reduction of semen quality, testicular volume, penile length, and anogenital distance. Experimental evidence points toward an antagonistic action of perfluorooctanoic acid on the binding of T to androgen receptor (AR) in a gene reporter assay, a competition assay on an AR-coated surface plasmon resonance chip, and an AR nuclear translocation assay.

DISCUSSION

This study documents that PFCs have a substantial impact on human health as they interfere with hormonal pathways, potentially leading to male infertility.

Endocrine Disruption of Androgenic Activity by Perfluoroalkyl Substances: Clinical and Experimental Evidence

BACKGROUND

Considerable attention has been paid to perfluoroalkyl compounds (PFCs) because of their worldwide presence in humans, wildlife, and environment. A wide variety of toxicological effects is well supported in animals, including testicular toxicity and male infertility. For these reasons, the understanding of epidemiological associations and of the molecular mechanisms involved in the endocrine-disrupting properties of PFCs on human reproductive health is a major concern.

OBJECTIVE

To investigate the relationship between PFC exposure and male reproductive health.

DESIGN

This study was performed within a screening protocol to evaluate male reproductive health in high schools.

PATIENTS

This is a cross-sectional study on 212 exposed males from the Veneto region, one of the four areas worldwide heavily polluted with PFCs, and 171 nonexposed controls.

MAIN OUTCOME MEASURES

Anthropometrics, seminal parameters, and sex hormones were measured in young males from exposed areas compared with age-matched controls. We also performed biochemical studies in established experimental models.

RESULTS

We found that increased levels of PFCs in plasma and seminal fluid positively correlate with circulating testosterone (T) and with a reduction of semen quality, testicular volume, penile length, and anogenital distance. Experimental evidence points toward an antagonistic action of perfluorooctanoic acid on the binding of T to androgen receptor (AR) in a gene reporter assay, a competition assay on an AR-coated surface plasmon resonance chip, and an AR nuclear translocation assay.

DISCUSSION

This study documents that PFCs have a substantial impact on human health as they interfere with hormonal pathways, potentially leading to male infertility.

Role of Viral Infections in Testicular Cancer Etiology: Evidence From a Systematic Review and Meta-Analysis

The most represented histotype of testicular cancer is the testicular germ-cell tumor (TGCT), both seminoma and non-seminoma. The pathogenesis of this cancer is poorly known. A possible causal relationship between viral infections and TGCTs was firstly evoked almost 40 years ago and is still a subject of debate. In the recent past, different authors have argued about a possible role of specific viruses in the development of TGCTs including human papillomavirus (HPV), Epstein-Barr virus (EBV), cytomegalovirus (CMV), Parvovirus B-19, and human immunodeficiency virus (HIV). The aim of this present review was to summarize, for each virus considered, the available evidence on the impact of viral infections on the risk of developing TGCTs. The review was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We included all observational studies reported in English evaluating the correlations between viral infections (HPV, CMV, EBV, Parvovirus B19, and HIV) and TGCTs. The methodological quality of studies included in the meta-analysis was evaluated using a modified version of the "Newcastle-Ottawa Scale." Meta-analyses were conducted using the "Generic inverse variance" method, where a pooled odds ratio (OR) was determined from the natural logarithm (LN) of the studies' individual OR [LN (OR)] and the 95% CI. A total of 20 studies (on 265,057 patients) were included in the review. Meta-analysis showed an association with TGCTs only for some of the explored viruses. In particular, no association was found for HPV, CMV, and Parvovirus B-19 infection (p = ns). Conversely, EBV and HIV infections were significantly associated with higher risk of developing TGCTs (OR 7.38, 95% CI 1.89-28.75, p = 0.004; OR 1.71, 95% CI 1.51-1.93, p < 0.00001). In conclusion, we found adequate evidence supporting an oncogenic effect of HIV and EBV on the human testis. Conversely, available data on HPV and TGCTs risk are conflicting and further studies are needed to draw firm conclusions. Finally, current evidence does not support an effect of CMV and Parvovirus B-19 on testicular carcinogenesis.

Prognostic Value of Ultrasound Stratigraphy in Long-Term Weight Loss: Results from a Nutritional Counseling Program

BACKGROUND

Weight control through lifestyle interventions represents a suitable strategy to avoid the metabolic, endocrine, and reproductive comorbidities associated with overweight and obesity. Reduced testosterone (T) levels are a worsening factor in overweight males. However, prognostic parameters of long-term weight loss are not readily available. Here, we tested the prognostic value of early variations of anthropometric and hormonal parameters, with a focus on ultrasound stratigraphy (US) and the reduction in body mass index (BMI) associated with nutritional counseling/lifestyle interventions at 6-month follow-up.

METHODS

Ninety-five male subjects (BMI 25-34.9 kg/m2) who had undergone nutritional/lifestyle interventions, were retrospectively analyzed for: body weight and composition; US evaluation at the triceps (TRC), abdominal (ABD), and thigh (THI) areas; and circulating levels of T, luteinizing hormone, and follicle-stimulating hormone. Sixty patients (63.2%) completed the 6-month follow-up program.

RESULTS

At 6 months, a significant reduction in BMI (26.38 ± 1.55 vs. 31.5 ± 5.0 basal, p < 0.001) and increase in T levels (18 ± 5.4 vs. 9.5 ± 2.3 nmol/L basal, p = 0.04) were observed. Subjects in the highest quartile of the BMI reduction at 6 months (ΔBMI 6 mo), compared to the lowest, showed a significant difference at the 2-month follow-up variation of BMI (p = 0.025), and fat and muscle thickness at the TRC (both p < 0.001) and ABD (p < 0.001 and p = 0.002, respectively) areas. Variation of TRC muscle thickness at 2 months was the only independent predictor of ΔBMI 6 mo in the multiple stepwise regression analysis.

CONCLUSIONS

BMI evaluation and US represent useful monitoring tools in the follow-up of nutritional/lifestyle interventions for overweight-to-mildly obese patients. The important effects on motivation and adherence to the intervention program are to be considered.

Novel insights on testicular volume and testosterone replacement therapy in Klinefelter patients undergoing testicular sperm extraction. A retrospective clinical study

STUDY QUESTION

To investigate whether sperm recovery is related to clinical features, hormone parameters and testosterone replacement therapy (TRT) in patients with Klinefelter syndrome (KS).

SUMMARY ANSWER

This study provides three interesting insights: (i) the probability to retrieve sperm is not related to testicular volume; (ii) TRT does not affect sperm retrieval rate (SRR); and (iii) reduced levels of LH and FSH represent a negative predictor of sperm retrieval in patients with TRT.

WHAT IS KNOWN ALREADY

Classical KS shows a karyotype with one extra X chromosome in all of somatic cells and clinical manifestations characterized by hypergonadotropic hypogonadism and infertility.

STUDY DESIGN, SIZE AND DURATION

We performed a retrospective cohort study. Data from 111 consecutive KS azoospermic patients undergoing testicular sperm extraction (TESE) were collected from 2005 to 2016.

PARTICIPANTS/MATERIALS, SETTING AND METHODS

Data on anthropometric parameters, reproductive hormones and testicular volumes were collected. SRR was related to clinical characteristics and compared between TRT and untreated patients.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 38 patients (34.2%) had successful sperm recovery. The comparison of clinical characteristics did not differ between patients with and without sperm recovery. Sperm retrieval was successful also in subjects with smaller testes. The comparison of SRR in patients with or without TRT was not different (33.3% vs 34.6%). In TRT group, LH and FSH levels were significantly lower in subjects with no sperm retrieval (P values, respectively, <.05 and <.001).

LIMITATIONS AND REASONS FOR CAUTION

Well-designed controlled studies are necessary to confirm these data aimed to set the best therapeutic approach for fertility management in hypogonadal patients with nonmosaic KS.

WIDER IMPLICATIONS OF THE FINDINGS

Age at TESE, anthropometric measures, testis volume, sex hormones levels and semen parameters are not predictive parameters of SRR. Among TRT patients, reduced gonadotropin is related to failure in sperm retrieval.

Outcome of Laparoscopic Splenectomy for Malignant Hematologic Diseases

Aim

The role of laparoscopic splenectomy in the treatment of hematological diseases is still controversial. The aim of this study was to assess whether the benign or malignant nature of hematological diseases may influence the outcome of laparoscopic splenectomy.

Patients and methods

Between August 1997 and March 2002, 63 unselected patients with hematologic diseases underwent a laparoscopic splenectomy. Patients were divided into two groups according to the benign (Group A, 38 patients) or malignant (Group B, 25 patients) nature of the hematological diseases.

Results

Patients in group B were significantly (a) older, (b) had larger spleens that more frequently needed accessory incisions for specimen retrieval, (c) had greater transfusion requirements, and (d) were fed later than patients in group A. There were no statistically significant differences among the two groups in terms of (a) body-mass index, (b) operative time, (c) conversion rate, (d) blood loss, (e) pain medication requirements, and (f) hospital stay. Two postoperative deaths occurred among patients in group B, but none of them was related to surgery.

Conclusions

The results of the study showed that: a) the nature of the disease does not influence the outcome of laparoscopic splenectomy, b) the size of the spleen might increase the risk of conversion, but it is no longer a contraindication to laparoscopic splenectomy, and c) laparoscopic splenectomy can be effectively performed in the treatment of malignant hematologic diseases.

Thrombotic Microangiopathy of the Miscellaneous Secondary Type Responding to Plasma Exchange in a Liver Transplant Recipient

A thrombotic microangiopathy syndrome, clinically and pathologically similar to thrombotic thrombocytopenic purpura (TTP) has been reported in recipients of tissue transplants, including renal and bone marrow allografts. The diagnosis is made only after other causes of microangiopathic hemolytic anemia have been excluded. In this case report we present the outcome of the combination of plasma exchange, dipyridamole and aspirin in the management of a TTP-like syndrome that complicated the post-operative course of liver transplantation.

Human Papillomavirus Prophylactic Vaccination improves reproductive outcome in infertile patients with HPV semen infection: a retrospective study

In this study we aimed to evaluate the effect on reproductive outcome of HPV vaccination in male subjects of infertile couples with HPV semen infection. In this single-center study, we retrospectively enrolled 151 infertile couples with detection of HPV in semen, attending our Hospital Unit of Andrology between January 2013 and June 2015, counseled to receive adjuvant HPV vaccination. Seventy-nine accepted vaccination (vaccine group) whilst 72 did not (control group). Our protocol of follow-up, aimed to evaluate HPV viral clearance, consisted in semen analysis, INNO-LiPA and FISH for HPV in semen cells after 6 and 12 months from basal evaluation. Spontaneous pregnancies, miscarriages and live births were recorded. Progressive sperm motility and anti-sperm antibodies were improved in the vaccine group at both time points (p < 0,05 vs control arm). Forty-one pregnancies, 11 in the control group and 30 in the vaccine group, were recorded (respectively 15% and 38,9%, p < 0,05) and resulted into 4 deliveries and 7 miscarriages (control group) and 29 deliveries and one miscarriage (vaccine group, p < 0,05 vs control group). HPV detection on sperms was predictive of negative pregnancy outcome. Adjuvant vaccination associated with enhanced HPV healing in semen cells and increased rate of natural pregnancies and live births.

Hypovitaminosis D is associated with erectile dysfunction in type 2 diabetes

Diabetes is an established risk factor for erectile dysfunction (ED). The pathophysiology of ED in diabetic men is multifactorial, but it mainly involves a vascular disorder related to a reduction of endothelial function. Recently, several studies have correlated ED risk factors with vitamin D deficiency. In this study, we evaluate the relationship between 25-hydroxyvitamin D [25(OH)D] levels, erectile dysfunction, and vascular disease, in type 2 diabetes mellitus men (T2DM). In this observational study, 92 T2DM males (58.83 ± 9.73 years) underwent medical history collection, International Index of Erectile Function (IIEF-5) questionnaire, that allows the identification and grading of DE, physical examination, biochemical/hormonal blood tests, and penile echo-color Doppler ultrasonography. T2DM patients with lower 25(OH)D levels (<25 nmol/l) showed higher penile IMT (p < 0.05), waist circonference (p < 0.05), glucose concentrations (p < 0.05), and lower IIEF-5 score (p < 0.005), testosterone concentrations (p < 0.05), and cavernous peak systolic velocity (PSV) (p < 0.05), compared to patients with 25(OH)D >50 nmol/l. 25(OH)D levels were directly correlated with IIEF-5 (R = 0.39; p = 0.0001), testosterone (R = 0.24; p = 0.02), and PSV (R = 0.24; p = 0.04) and inversely with waist (R = -0.33; p = 0.002), HbA1c (R = -0.22; p = 0.03), triglyceride (R = -0.21; p = 0.06), and penile IMT (R = -0.30; p = 0.009). At multivariate analysis, 25(OH)D deficiency remained an independent predictor of DE. We demonstrate a significant association between 25(OH)D deficiency and erectile dysfunction in T2DM men. This association may be due to the influence of 25(OH)D deficiency on cardiovascular risk factor (glycaemia, HDL cholesterol, and triglycerides), testosterone plasma levels and endothelial dysfunction.

Long-term outcome on kidney retransplantation: a review of 100 cases from a single center

Renal transplantation has become an effective form of treatment for end-stage renal failure. Unfortunately, as a consequence of immunological and nonimmunological pathogenic mechanisms, chronic allograft nephropathy is responsible for the loss of a large proportion of kidney grafts after several years and return to dialysis. We have reported herein our 24 years of experience with second kidney transplantations. Of 1,302 kidney transplantations between January 1983 and June 2007 performed in our transplantation center, 100 were second transplantations. Kidney retransplantation was performed in 74 men and 26 women of overall mean age of 35.4 +/- 12.6 years. Cadaveric donor grafts were transplanted in 92 patients, whereas the remaining 8 were living-related donor kidneys. At 1, 5, and 10 years after kidney transplantation, patient survival rates were 100%, 96%, and 92%, respectively, whereas graft survival rates were 85%, 72%, and 53%, respectively. Immunosuppressive therapy included induction therapy with polyclonal anti-lymphocyte antibodies (ALG/ATG) or (starting from 1999) monoclonal anti CD 25 antibody. Our results demonstrated good outcomes for kidney retransplantations with allocation based on anti- HLA antibody identification together with induction immunosuppression.

Torque Teno Virus--cause of viral liver disease following liver transplantation: a case report

Torque Teno Virus (TTV), a nonenveloped human virus of the Circoviridae family, is hepatotropic, causing liver damage, cirrhosis, and, rarely, fulminant hepatitis. It prevails in 10% to 75% of blood donors due to environmental differences, independent of chronic hepatitis B virus (HBV)/HCV hepatitis, cryptogenic cirrhosis, alcoholic cirrhosis, and in fulminant hepatitis non-A-G. Reports about the efficacy of clinical alpha interferon are rare. In July 2007, a 65-year-old man who was serologically negative for A-E viruses presented with acute liver failure due to a ruptured hepatic artery aneurysm and underwent orthotopic liver transplantation (OLT). Immunosuppression was based on cyclosporine and steroids. At postoperative day 20, there was persistent hypertransaminasemia with otherwise normal liver function. A percutaneous hepatic biopsy documented pattern suggestive of a viral etiology. Multiple tests for hepatotropic viruses in the donor and the recipient from the pre- and post-OLT periods remained negative. Only the TTV qualitative test, assessed by polymerase chain reaction (PCR) on patient sera, was positive. Immunosuppressive therapy was not changed; no antiviral therapy was undertaken. At 6 months posttransplantation, transaminase levels spontaneously normalized and the clinical situation was unchanged. No complications were observed; the patient is in good clinical condition. No graft rejection was observed. In histologically proven non-A-E viral hepatitis, it is important to consider TTV as an incidental pathogenic agent. It may be useful to extend virological tests to TTV among transplant recipients and donors and to gain further knowledge about this virus.

Laparoscopic approach for down-staging in hepatocellular carcinoma patients who are candidates for liver transplantation

INTRODUCTION

The aim of this study was to assess the impact of laparoscopic thermoablation (LTA) and laparoscopic resection (LR) as neoadjuvant therapy before orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC).

METHODS

From June 2005 to November 2010, 50 consecutive patients affected by HCC with liver cirrhosis were treated with LTA under ultrasound guidance or LR. Of them, 10 patients (mean age, 58.3 ± 5.59 years; male:female, 8:2) underwent OLT. They were mostly Child-Pugh class A (80%).

RESULTS

A LTA of 12 nodules was achieved in 7 patients and an LR of 3 HCC nodules in the other 3 subjects. The mean length of surgery was 163 minutes (range; 60-370). The mean hospital stay was 6.1 days. Transient mild postoperative liver failure was reported in 1 case. Complete tumor necrosis was observed in 10 thermoablated nodules (83.3%) via spiral computerized tomographic scan at 1 month after treatment; the resected patients showed absence of recurrence. All patients underwent OLT after a mean interval of 7 months. The histology of the native liver showed complete necrosis in 9/12 thermoablated nodules (75%); a recurrence at surgical site occurred in 1 patient in the resection group.

CONCLUSIONS

Laparoscopic ultrasound can be used in potential OLTs candidates to accurately stage HCC in advanced cirrhosis with minimal morbidity. LTA and LR proved to be safe and effective techniques for HCC patients, representing a valid "bridge" to OLT.

Impact of Model for End-Stage Liver Disease score on transfusion rates in liver transplantation

BACKGROUND

Liver transplantation (OLT) can entail a high risk of blood loss requiring transfusions, which increase morbidity and mortality. In recent years many efforts have been spent to improve the surgical and anesthetic management to decrease transfusion rates during OLT. Preoperative predictors for transfusion in OLT, remain uncertain.

METHODS

We retrospectively reviewed the 219 OLT performed from 2005 to 2011 focusing on blood product (BP) transfusions. Statistical analysis sought the impact of transfusions on OLT outcomes to identify possible independent predictors of higher BP requirements.

RESULTS

The 1- and 3-year survival rates were 86.6% and 76.45% for patients and 81.0% and 71.8% for grafts respectively. The mean intra- and perioperative red blood cell (RBC) transfusion rates were 12.3 ± 11.7 U and 15.5 ± 13.0 U respectively. A statistical analysis demonstrated a significant influence of BP transfusion on post-OLT complications and survivals. Multivariate logistic regression analysis showed the Model for End-Stage Liver Disease (MELD) score to be the only independent predictor of perioperative RBC transfusions.

CONCLUSIONS

Our results confirmed the link between intra- and perioperative transfusions and outcome of OLT patients. MELD score resulted the only independent variable associated with increased perioperative RBC transfusions.

A Bayesian methodology to improve prediction of early graft loss after liver transplantation derived from the liver match study

BACKGROUND

To generate a robust predictive model of Early (3 months) Graft Loss after liver transplantation, we used a Bayesian approach to combine evidence from a prospective European cohort (Liver-Match) and the United Network for Organ Sharing registry.

METHODS

Liver-Match included 1480 consecutive primary liver transplants performed from 2007 to 2009 and the United Network for Organ Sharing a time-matched series of 9740 transplants. There were 173 and 706 Early Graft Loss, respectively. Multivariate analysis identified as significant predictors of Early Graft Loss: donor age, donation after cardiac death, cold ischaemia time, donor body mass index and height, recipient creatinine, bilirubin, disease aetiology, prior upper abdominal surgery and portal thrombosis.

RESULTS

A Bayesian Cox model was fitted to Liver-Match data using the United Network for Organ Sharing findings as prior information, allowing to generate an Early Graft Loss-Donor Risk Index and an Early Graft Loss-Recipient Risk Index. A Donor-Recipient Allocation Model, obtained by adding Early Graft Loss-Donor Risk Index to Early Graft Loss-Recipient Risk Index, was then validated in a distinct United Network for Organ Sharing (year 2010) cohort including 2964 transplants. Donor-Recipient Allocation Model updating using the independent Turin Transplant Centre dataset, allowed to predict Early Graft Loss with good accuracy (c-statistic: 0.76).

CONCLUSION

Donor-Recipient Allocation Model allows a reliable donor and recipient-based Early Graft Loss prediction. The Bayesian approach permits to adapt the original Donor-Recipient Allocation Model by incorporating evidence from other cohorts, resulting in significantly improved predictive capability.

Endovascular treatment with primary stenting of inferior cava vein torsion following orthotopic liver transplantation with modified piggyback technique

PURPOSE

This study was undertaken to evaluate primary stenting in patients with inferior vena cava torsion after orthotopic liver transplantation performed with modified piggyback technique.

MATERIALS AND METHODS

From November 2003 to October 2010, six patients developed clinical, laboratory and imaging findings suggestive of caval stenosis, after a mean period of 21 days from an orthotopic liver transplantation performed with modified piggyback technique. Vena cavography showed stenosis due to torsion of the inferior vena cava at the anastomoses and a significant caval venous pressure gradient. All patients were treated with primary stenting followed by in-stent angioplasty in three cases.

RESULTS

In all patients, the stents were successfully positioned at the caval anastomosis and the venous gradient pressure fell from a mean value of 10 to 2 mmHg. Signs and symptoms resolved in all six patients. One patient died 3 months after stent placement due to biliary complications. No evidence of recurrence or complications was noted during the follow-up (mean 49 months).

CONCLUSIONS

Primary stenting of inferior vena cava stenosis due to torsion of the anastomoses in patients receiving orthotopic liver transplantation with modified piggyback technique is a safe, effective and durable treatment.

Laparoscopic liver resection for hepatocellular carcinoma in cirrhotic patients. Feasibility of nonanatomic resection in difficult tumor locations

BACKGROUND:

Surgical resection for hepatocellular carcinoma (HCC) in cirrhotic patients remains controversial because of high morbidity and recurrence rates. Laparoscopic resection of liver tumors has recently been developed and could reduce morbidity. The aim of this study was to evaluate retrospectively our results for laparoscopic liver resection (LLR) for HCC including lesions in the posterosuperior segments of the liver in terms of feasibility, outcome, recurrence and survival.

MATERIALS AND METHODS:

Between June 2005 and February 2009, we performed 20 LLR for HCC. Median age of the patients was 66 years. The underlying cirrhosis was staged as Child A in 17 cases and Child B in 3.

RESULTS:

LLR included anatomic resection in six cases and nonanatomic resection in 14. Eleven procedures were associated in nine (45%) patients. Median tumor size and surgical margins were 3.1 cm and 15 mm, respectively. A conversion to laparotomy occurred in one (5%) patient for hemorrhage. Mortality and morbidity rates were 0% and 15% (3/20). Median hospital stay was 8 days (range: 5-16 days). Over a mean follow-up period of 26 months (range: 19–62 months), 10 (50%) patients presented recurrence, mainly at distance from the surgical site. Treatment of recurrence was possible in all the patients, including orthotopic liver transplantation in three cases.

CONCLUSIONS:

LLR for HCC in selected patients is a safe procedure with good short-term results. It can also be proposed in tumor locations with a difficult surgical access maintaining a low morbidity rate and good oncological adequacy. This approach could have an impact on the therapeutic strategy of HCC complicating cirrhosis as a treatment with curative intent or as a bridge to liver transplantation.

Kidney transplantation from living donors genetically related or unrelated to the recipients: a single-center analysis

Living-donor programs have gradually become an attractive strategy to expand the donor pool for kidney transplantation (KT). Grafts from living-related donors (LRD) display superior function and longer survival than those obtained from cadaveric sources. Recent reports have shown that outcomes from living-unrelated donors (LUD) are not worse than those from LRD. In this study, we evaluated 135 procedures using living donors performed in our center between 1987 and 2010 (LRD: n = 111; LUD: n = 24). Among the LRD, most donors were mothers (n = 61; 54.95%), fathers (n = 25; 22.52%), and sisters (n = 16; 14.41%). The LUD included wives (n = 17; 70.83%) and husbands (n = 7; 29.17%). The mean recipient ages for LRD versus LUD were 26.94 ± 13.51 and 50.04 ± 8.86 years, respectively (P < .0001). The recipient female/male distribution was 33/78 (29.73%/70.27%) for the LRD versus 6/18 (25%/75%) for the LUD group (P = .643). The donor age was 48.79 ± 9 years in LRD and 49.25 ± 8.44 years in LUD (P = .696). The donor female/male distribution was 72/39 (64.86%/35.16%) in LRD and 17/7 (70.83%/29.17%) in LUD (P = .576). The follow up was 123.79 ± 87.87 months (range, 0.91-279.93). Overall patient and graft survivals were 94.1% and 67.6%, respectively. There was no significant difference in patient survival after stratifying for donor type (LRD: 93.9%; LUD: 95.8%; P = .961) or in graft survival after stratifying for donor type (LRD: 63.8%; LUD: 87.8%; P = .124). Entering donor type as an independent variable in a univariate Cox regression, we observed no significance for either recipient (P = .961) or graft survival (P = .142). The results of this study suggest that LUD utilization should be encouraged in KT programs.

Laparoscopic resection of hepatocellular carcinoma. Considerations on lesions in the posterosuperior segments of the liver

AIM

The aim of this study was to evaluate retrospectively our results for laparoscopic liver resection (LLR) of hepatocellular carcinoma (HCC) including lesions in the posterosuperior segments of the liver in terms of feasibility, outcome, recurrence and survival.

MATERIAL OF STUDY

Between June 2005 and May 2009, we performed 22 LLR for HCC. The underlying cirrhosis was staged as Child A in 19 cases and Child B in 3.

RESULTS

LLR included a non anatomic resection in 15 cases and an anatomic resection in 7. A conversion to laparotomy occurred in one (4.5%) patient for hemorrhage. Mortality and morbidity rates were 0% and 18.1% (4/20). Over a mean follow-up period of 29 months (range: 19-65 months), 11 (50%) patients presented recurrence, mainly at distance from the surgical site.

DISCUSSION

A laparoscopic approach is more suitable when the lesion is located in the peripheral "laparoscopic" segments 2 to 6. Nevertheless, six resections were made in the posterosuperior segments. Although parenchymal-sparing resection is required by the presence of underlying liver disease, anatomic resection has always to be considered and pursued to reduce local recurrence. In our series the recurrence rate was similar to those reported for other laparoscopic studies and for open resection of HCC.

CONCLUSIONS

LLR for HCC in selected patients is a safe procedure with good short-term results. It can also be proposed in tumor locations with a difficult surgical access maintaining a low morbidity rate and good oncologic adequacy. This approach could have an impact on the therapeutic strategy of HCC complicating cirrhosis as a treatment with curative intent or as a bridge to liver transplantation.

A single-center analysis to evaluate kidney function parameters after liver transplantation in adult patients

Severe renal dysfunction may occur after orthotopic liver transplantation (OLT). In this study, we retrospectively analyzed a single-center series of adult liver recipients (n = 62) seeking to identify patients prone to develop renal dysfunction during follow-up. Liver recipients (age range, 53.54 ± 8.19 years; female/male: 21/41) who underwent a first OLT from a brain dead donor were enrolled according to strict criteria. We enrolled only liver recipients with 5 serum creatinine (SCr) measurements after hospital discharge and at least 1 measurement/year with a follow-up period of not less than 2 years. We estimated glomerular filtration rate (eGFR) using the formula developed by the Mayo Clinic. The average rate of SCr change after OLT was 0.0065 ± 0.013 mg/dL/mo. By calculating the per-patient slope, the average rate of SCr change was 0.000165 ± 0.000383 mg/dL (0.000007 ± 0.000017 mg/dL/mo). In regression models evaluated with SCr as the dependent variable versus post-OLT time, no significance was observed (P = .130). The average rate of eGFR change after OLT was -0.462 ± 0.883 mL/min/mo. By calculating the per-patient slope, the average rate of eGFR change was -0.009 ± 0.0026 mL/min (-0.0004 ± 0.0012 mL/min/mo). In the regression models evaluated with eGFR as dependent variable versus post-OLT time, no significance occurred (P = .168). By applying the regression prediction to SCr at 3 to 5 versus the 1 to 2 post-OLT measurements, we noted 3 male liver recipients (MLR) whose SCr values were significantly higher than the predicted values: MLR1: P = .048 at measurement 4; MLR2: P = .019 at measurement 4; and MLR3: P = .017 at measurement 5. Conversely, we did not observed a significant difference between observed versus predicted eGFR values. Clinical decisions on immunosuppressive treatments for liver recipients should be determined also on the basis of the series of post-OLT kidney function, which should be studied with rigorous evaluation of fitted regression models.

Laparoscopic right posterior sectionectomy for hepatocellular carcinoma using a modified liver-hanging maneuver

BACKGROUND

Posterosuperior liver segments are the most difficult locations for laparoscopy to access. This location is considered by most surgeons to be a poor indication for a laparoscopic liver resection due to the limited visualization and the difficulty of controlling bleeding. The liver-hanging maneuver (LHM) is a technique taking aim at reducing intraoperative blood loss through an open approach.

METHODS

We report our early experience on adopting a modified liver-hanging technique to perform a totally laparoscopic right posterior sectionectomy to remove a 5-cm hepatocellular carcinoma located in Couinaud's segments 6 and 7.

RESULTS

The procedure was completed laparoscopically with acceptable time of surgery and blood loss. A 3.5-cm tumor-free resection margin was achieved. The patient was discharged on postoperative Day 10 without complications. No evidence of recurrence was seen at the 12-month follow-up.

CONCLUSIONS

Total laparoscopic posterior sectionectomy using a modified LHM is a possible operative procedure greatly facilitating surgical manipulation. This maneuver was successfully used to mobilize the liver, to guide the hepatic transection, and to prevent bleeding. The potential advantages of this procedure should be evaluated in a comparative study on a large number of patients.

Early effects of portal flow modulation after extended liver resection in rat

INTRODUCTION

The incidence of small-for-size-liver-syndrome after liver transplantation and extended liver resection may be reduced by portal flow modulation. However, many aspects of the small-for-size-liver-syndrome pathogenesis are still unclear. In this experimental study we evaluated the early effects of portal flow modulation after 80% hepatic resection in rats.

MATERIALS AND METHODS

Rats were randomised in: sham operation (G1), conventional hepatic resection (G2), splenectomy and hepatic resection (G3), splenic transposition followed by hepatic resection after three weeks (G4). Six hours after operation, oxygen saturation of hepatic vein blood, glutathione, and standard liver markers were measured from hepatic venous blood. Glutathione measurement and histopatological examination were performed in the remnant liver.

RESULTS

Total bilirubin and liver glutathione did not show differences between groups. Aspartate aminotransferase and alanine aminotransferase significantly increased in G2-G4 groups. Blood glutathione and oxygen saturation of hepatic vein blood were lower in G2 than in other groups. A gradient of micro-vesicular degeneration was more severe in G2 compared with G3 and G4. Apoptosis, hemorrhagic necrosis, mitochondrial damage and leucocyte adhesion were evident in G2.

CONCLUSION

The portal flow modulation induced by splenectomy or splenic transposition was effective in limiting early damage after extended liver resection.

Hepatic flow optimization in full right split liver transplantation

Split liver transplantation for two adults offers a valuable opportunity to expand the donor pool for adult recipients. However, its application is mainly hampered by the physiological limits of these partial grafts. Small for size syndrome is a major concern during transplantation with partial graft and different techniques have been developed in living donor liver transplantation to prevent the graft dysfunction. Herein, we report the first application of synergic approaches to optimise the hepatic hemodynamic in a split liver graft for two adults. A Caucasian woman underwent liver transplantation for alcoholic cirrhosis (MELD 21) with a full right liver graft (S5-S8) without middle hepatic vein. Minor and accessory inferior hepatic veins were preserved by splitting the vena cava; V5 and V8 were anastomosed with a donor venous iliac patch. After implantation, a 16G catheter was advanced in the main portal trunk. Inflow modulation was achieved by splenic artery ligation. Intraportal infusion of PGE1 was started intraoperatively and discontinued after 5 d. Graft function was immediate with normalization of liver test after 7 d. Nineteen months after transplantation, liver function is normal and graft volume is 110% of the recipient standard liver volume. Optimisation of the venous outflow, inflow modulation and intraportal infusion of PGE1 may represent a valuable synergic strategy to prevent the graft dysfunction and it may increase the safety of split liver graft for two adults.

Italian continuing medical education program: an evidence-based course for surgeons and health personnel of a regional transplantation center

In the organ transplantation area the application of the evidence-based medicine (EBM) methods may be limited by several, heterogeneous conditions, eg, mandatory laws and protocols, logistic concerns, as well as donor/recipient matching. In this report we have described the results of a first EBM-oriented course for surgeons and health personnel in a regional transplantation center under the Italian Continuing Medical Education (CME) program. The course was formally approved for 25 credits. It included a maximum of 70 medical and nursing staff registrants; 50 of the spots were reserved for our transplantation center. The course was scheduled in 10 sessions from June to November 2010. Each session was composed of 2 phases: (1) first, computer-assisted education including slide presentations (2 hours); and (2) subsequent discussion led by experts (1.5 hours). The registered participants were expected to be able to correctly answer a multiple-choice, 10-question questionnaire at the end of each session. The majority of the participants considered the course relevant to their need to be updated and effective to improve their clinical skills. The requirements to obtain credits by the Italian CME program for live events were overall presence ≥80% and correct responses in the postsession questionnaires ≥70%. However, among the initially registered participants 31.5% failed at least one of these requirements. The main reason for failure was exceeding the maximum number of absences. Paradoxically, the absences were largely caused by the simultaneous execution of surgical/medical transplantation procedures. For professional figures engaged in complex medical activities, the Italian CME program should consider different threshold limits for the maximum number of absences allowed at live events.

Simultaneous laparoscopic anterior resection and left hepatic lobectomy for stage IV rectal cancer

We report the case of a 68-year-old female patient affected by rectal cancer and a synchronous metastatic lesion measuring 8 cm in diameter in the left hepatic lobe. After a laparoscopic ultrasonography exploration of the liver to detect possible occult metastases, a simultaneous colorectal resection and a left hepatic lobectomy including a partial resection of segment IV were performed. Five ports were used for the entire procedure. The resected specimens were extracted through a Pfannenstiel incision. The procedure was completed laparoscopically. Total operative time was 455 minutes with negligible intraoperative blood loss. The postoperative hospital stay was 12 days. At 4-month follow-up, the patient recovered completely. A computed tomography scan performed at this time showed no signs of recurrent disease. This report confirms the feasibility of the laparoscopic approach to simultaneous hepatic and colorectal resections in stage IV rectal cancer. The known advantages of the miniinvasive approach could make such complex procedures more endurable.

Reversed arterial flow in the paramedian segments of the liver after pancreaticoduodenectomy

Variation of splanchnic arterial anatomy is frequent and may complicate pancreatic surgery, leading to life-threatening postoperative complications. We report a case of severe hepatic dysfunction after pancreaticoduodenectomy due to accidental section of the right hepatic artery. Bedside ultrasound examination showed a reversed arterial flow in the paramedian segments of the liver. Based on intraoperative and ultrasound findings, a retrograde arterial supply of the right liver from the left hepatic artery through spontaneous anastomosis between the arteries of segment 4 and the right paramedian segments was assumed and confirmed by postoperative CT examination.

Liver Match, a prospective observational cohort study on liver transplantation in Italy: study design and current practice of donor-recipient matching

BACKGROUND

The Liver Match is an observational cohort study that prospectively enrolled liver transplantations performed at 20 out of 21 Italian Transplant Centres between June 2007 and May 2009. Aim of the study is to investigate the impact of donor/recipient matching on outcomes. In this report we describe the study methodology and provide a cross-sectional description of donor and recipient characteristics and of graft allocation.

METHODS

Adult primary transplants performed with deceased heart-beating donors were included. Relevant information on donors and recipients, organ procurement and allocation were prospectively entered in an ad hoc database within the National Transplant Centre web-based Network. Data were blindly analysed by an independent Biostatistical Board.

RESULTS

The study enrolled 1530 donor/recipient matches. Median donor age was 56 years. Female donors (n = 681, median 58, range 12-92 years) were older than males (n = 849, median 53, range 2-97 years, p < 0.0001). Donors older than 60 years were 42.2%, including 4.2% octogenarians. Brain death was due to non-traumatic causes in 1126 (73.6%) cases. Half of the donor population was overweight, 10.1% was obese and 7.6% diabetic. Hepatitis B core antibody (HBcAb) was present in 245 (16.0%) donors. The median Donor Risk Index (DRI) was 1.57 (>1.7 in 35.8%). The median cold ischaemia time was 7.3h (≥ 10 in 10.6%). Median age of recipients was 54 years, and 77.7% were males. Hepatocellular carcinoma (HCC) was the most frequent indication overall (44.4%), being a coindication in roughly 1/3 of cases, followed by viral cirrhosis without HCC (28.2%) and alcoholic cirrhosis without HCC (10.2%). Hepatitis C virus infection (with or without HCC) was the most frequent etiologic factor (45.9% of the whole population and 71.4% of viral-related cirrhosis), yet hepatitis B virus infection accounted for 28.6% of viral-related cirrhosis, and HBcAb positivity was found in 49.7% of recipients. The median Model for End Stage Liver Disease (MELD) at transplant was 12 in patients with HCC and 18 in those without. Multivariate analysis showed a slight but significant inverse association between DRI and MELD at transplant.

CONCLUSIONS

The deceased donor population in Italy has a high-risk profile compared to other countries, mainly due to older donor age. Almost half of the grafts are transplanted in recipients with HCC. Higher risk donors tend to be preferentially allocated to recipients with HCC, who are usually less ill and older. No other relevant allocation strategy is currently adopted at national level.

Biochemical and morphologic effects after extended liver resection in rats: preliminary results

After hepatic resection and transplantation with a partial graft, death and regeneration of the hepatocytes coexist in the liver. However, when the functional liver mass is inadequate to ensure a proper balance between regeneration vs functional and metabolic demands, small-for-size syndrome develops. We assessed the early effects of extended hepatic resection on liver function in a rat model. Six male Sprague-Dawley rats underwent 80% resection of the liver, and 6 rats served as a control group. At 6 hours after resection, blood samples were obtained from the hepatic vein for measurement of reduced glutathione (GSH), oxidized glutathione (GSSG), and hepatic venous oxygen saturation (Shvo(2)), and for standard liver function tests including determination of concentrations of alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma-glutamyl transpeptidase, and total bilirubin. The remnant lobe was removed for GSH assay and histopathologic analysis. In the resection group, values were significantly higher for ALT (P = .002), AST (P = .002), and Shvo(2) (P = .01), whereas a significant decrease was observed for blood GSH (P = .009) but not liver GSH. Also in the resection group, we observed characteristic hepatocyte vacuolization with a gradient from periportal acinar zone 1 to the centrolobular area, the presence of hemorrhagic necrosis, and several leukocyte adhesions. The Shvo(2) and GSH data suggest early alteration of oxygen metabolism, as demonstrated by the reduction in oxygen uptake and decreased liver GSH secretion, with preservation of hepatic GSH. Mitochondrial dysfunction and oxidative injury seem to have a crucial role in early onset of liver damage.

Application and validation of Cox regression models in a single-center series of double kidney transplantation

A useful approach to reduce the number of discarded marginal kidneys and to increase the nephron mass is double kidney transplantation (DKT). In this study, we retrospectively evaluated the potential predictors for patient and graft survival in a single-center series of 59 DKT procedures performed between April 21, 1999, and September 21, 2008. The kidney recipients of mean age 63.27 +/- 5.17 years included 16 women (27%) and 43 men (73%). The donors of mean age 69.54 +/- 7.48 years included 32 women (54%) and 27 men (46%). The mean posttransplant dialysis time was 2.37 +/- 3.61 days. The mean hospitalization was 20.12 +/- 13.65 days. Average serum creatinine (SCr) at discharge was 1.5 +/- 0.59 mg/dL. In view of the limited numbers of recipient deaths (n = 4) and graft losses (n = 8) that occurred in our series, the proportional hazards assumption for each Cox regression model with P < .05 was tested by using correlation coefficients between transformed survival times and scaled Schoenfeld residuals, and checked with smoothed plots of Schoenfeld residuals. For patient survival, the variables that reached statistical significance were donor SCr (P = .007), donor creatinine cleararance (P = .023), and recipient age (P = .047). Each significant model passed the Schoenfeld test. By entering these variables into a multivariate Cox model for patient survival, no further significance was observed. In the univariate Cox models performed for graft survival, statistical significance was noted for donor SCr (P = .027), SCr 3 months post-DKT (P = .043), and SCr 6 months post-DKT (P = .017). All significant univariate models for graft survival passed the Schoenfeld test. A final multivariate model retained SCr at 6 months (beta = 1.746, P = .042) and donor SCr (beta = .767, P = .090). In our analysis, SCr at 6 months seemed to emerge from both univariate and multivariate Cox models as a potential predictor of graft survival among DKT. Multicenter studies with larger recipient populations and more graft losses should be performed to confirm our findings.

Single-center experience in double kidney transplantation

Use of organs from marginal donors for transplantation is a current strategy to expand the organ donor pool. Its efficacy is universally accepted among data from multicenter studies. Herein, we have reviewed outcomes of double kidney transplantation (DKT) over an 9-year experience in our center. The aim of this study was to evaluate possible important differences between a monocenter versus multicenter studies. Between 1999 and 2008, we performed 59 DKT. Recipient mean age was 63 +/- 5 years. Mean HLA-A, -B, and -DR mismatches were 3.69 +/- 0.922. Donor mean age was 69 +/- 7 years and mean creatinine clearance was 69.8 +/- 30.8 mL/min. Proteinuria was detected in three donors (5%). Mean cold ischemia and warm ischemia times were 1130 +/- 216 and 48 +/- 11 minutes, respectively. The right and left kidney scores were 4.18 +/- 2 and 4.21 +/- 2, respectively. Thirty patients (51%) displayed good postoperative renal function; 22 (37%), acute tubular necrosis with postoperative dialysis; 3 (5%), acute rejection episodes; 4 (7%), single-graft transplantectomy due to vascular thrombosis; 1 (2%), a retransplantation; 5 (8%), a lymphocele; 3 (5%) vescicoureteral reflux or stenosis requiring surgical correction. Cytomegalovirus infection was detected in five patients (8%). In three patients (5%) displayed de novo neoplasia. Three patients showed chronic rejection (5%), whereas we observed a cyclosporine-related toxicity in 7 (12%). Nine patients (15%) developed iatrogenic diabetes. Patient and graft survivals after 3 years from DKT were 93% and 86.3%, respectively. In this study, we applied successfully a widespread score to allocate organs to single kidney transplantation or DKT. In our experience, the score is suitable for the organ allocation but it may be overprotective, excluding potentially suitable organs for a single transplantation.

A time series analysis performed on a 25-year period of kidney transplantation activity in a single center

Following the example of many Western countries, where a "minimum volume rule" policy has been adopted as a quality parameter for complex surgical procedures, the Italian National Transplant Centre set the minimum number of kidney transplantation procedures/y at 30/center. The number of procedures performed in a single center over a large period may be treated as a time series to evaluate trends, seasonal cycles, and nonsystematic fluctuations. Between January 1, 1983, and December 31, 2007, we performed 1376 procedures in adult or pediatric recipients from living or cadaveric donors. The greatest numbers of cases/y were performed in 1998 (n = 86) followed by 2004 (n = 82), 1996 (n = 75), and 2003 (n = 73). A time series analysis performed using R Statistical Software (Foundation for Statistical Computing, Vienna, Austria), a free software environment for statistical computing and graphics, showed a whole incremental trend after exponential smoothing as well as after seasonal decomposition. However, starting from 2005, we observed a decreased trend in the series. The number of kidney transplants expected to be performed for 2008 by using the Holt-Winters exponential smoothing applied to the period 1983 to 2007 suggested 58 procedures, while in that year there were 52. The time series approach may be helpful to establish a minimum volume/y at a single-center level.

Para- and perirenal fat thickness is an independent predictor of chronic kidney disease, increased renal resistance index and hyperuricaemia in type-2 diabetic patients

BACKGROUND

Many interfering factors may reduce the reliability of waist circumference (WC) measurement in estimating the risk for chronic kidney disease (CKD) associated with obesity. Therefore, we determined the independent associations of para- and perirenal ultrasonographic fat thickness with the main markers of kidney function.

METHODS

A cross-sectional study was performed in 151 type-2 diabetic subjects. Para- and perirenal fat thickness was measured from the inner side of the abdominal musculature to the surface of the kidneys. CKD was defined as eGFR < 60 mL min(-1)1.73 m(-2).

RESULTS

Using both univariate and multivariate regression analyses, eGFR, renal resistance index and uricaemia were best predicted by para- and perirenal fat thickness even when BMI and waist circumference were further added in the statistical model (r(2): 0.366, P = 0.001; r(2): 0.529, P = 0.005; r(2): 0.310, P = 0.026, respectively), whereas waist circumference and BMI did not contribute independently of para- and perirenal fat thickness. Albuminuria was predicted by waist circumference but not by para- and perirenal fat thickness. In subjects with waist circumference above the diagnostic values of metabolic syndrome (48M/59F), eGFR significantly and progressively declined across tertiles of para- and perirenal fat thickness (87.0 ± 27.9 vs 83.5 ± 26.0 vs 62.3 ± 30.6 mL min(-1) 1.73 m(-2), adjusted P < 0.0001) despite comparable waist circumference, and an increasing frequency of CKD was observed across tertiles of subjects with waist circumference both below and above the metabolic syndrome diagnostic values (P < 0.05).

CONCLUSIONS

Para- and perirenal fat thickness is an independent predictor of kidney dysfunction in type-2 diabetes explaining an important proportion of the variance of eGFR, renal resistance index and uricaemia.

Percutaneous embolization of periduodenal varix due to portal hypertension in a patient with kidney-pancreas transplantation: a case report

Kidney-pancreas transplantation is a valid therapeutic option for patients with insulin-dependent diabetes mellitus. However, vascular complications associated with pancreas transplantation are not uncommon. Herein we have reported a 32-year-old woman with a history of insulin-dependent diabetes mellitus and celiac disease. She underwent liver transplantation for acute hepatitis. After 7 years, the patient developed end-stage kidney disease beginning hemodialysis and being listed for a kidney-pancreas transplantation, which was successfully performed when she was 29 years old with enteric diversion (Roux intestinal loop reconstruction). Five years after kidney-pancreas transplantation, she was admitted to our hospital with serious intestinal bleeding and poor liver function. The ultrasound showed a pattern like a arteriovenous fistula near the head of the pancreas. Computed Tomography was not diagnostic; an arteriogram showed the presence of a mesenteric varix and a mesenteric-caval shunt through the duodenum of the pancreatic graft. The liver biopsy and portal pressure gradient showed portal hypertension and liver cirrhosis. To obtain time a waiting a new liver, the patient underwent percutaneous embolization of the mesenteric varix through jugular access. The procedure was uneventful. The patient was successfully transplanted 2 months later. Pancreas function was always satisfactory.

Impact of the Italian continuing medical education program on the research production of a transplantation center: a preliminary analysis

In Italy, a Continuing Medical Education (CME) program that engages about one million health professionals involved with different roles in National Health Service (physicians, nurses, biologists, pharmacologists, psychologists, veterinarians, technicians, etc) became officially mandatory on January 1, 2008. In Italy, the traditional form of acquiring CME credits is to attend lectures and conferences, while the main structured online service was dismissed in November 2008. The Italian Ministry of Health required health professionals to obtain 50 credits/y, with no obligation toward scientific production. In this study, we have preliminarily evaluated the potential impact of a compulsory CME program on the research production of our transplantation center. We selected the research products published by surgeons (n = 10) and university researchers (n = 2) who were on duty in our center from 1995 to 2007. For this period, PubMed returned 89 research products with at least one surgeon/researcher of our center as author/coauthor. The mean number of published research products/y was 6.84 +/- 4.5. The number of expected research products for 2008 and 2009 on the basis of a time series analysis applied to the period 1995 to 2007 was 12.35 and 12.91, respectively. A search in PubMed restricted to 2008 and 2009 (from January 1 to November 23) returned in both years eight research products. Considering that in our center there was no increase in volume activities or changes in whole working processes, it seems reasonable to assume that the new compulsory, time-consuming Italian CME program may have played a role in the decline of scientific production. A systematic monitoring should be started with the aim to investigate the potential impact of the Italian CME program on biomedical research output, especially for centers and disciplinary areas mainly involved in clinical research.

[Pneumocystis jiroveci and cytomegalovirus pneumonia in patients with alcoholic hepatic cirrhosis]

We have described a fatal case of interstitial pneumonia with pleuritis in woman, 54 years old, suffered from end stage liver disease caused by ethanolic hepatic cirrhosis. Broncholavage microbiological culture was negative but biomolecular assays with polymerase chain reaction demonstred Pneumocystis jiroveci and Cytomegalovirus. She died despite aetiological therapy with cotrimoxazole and gancyclovir. Immunodeficiency of the delayed immune response, related to the severe liver disease and ethanol use, explains the occurrence of these opportunistic infections in ethanolic cirrhotic patients too.

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)

Giant mid-esophageal diverticulum. Conservative treatment of postoperative leakage

Mid-esophageal diverticula are rare entities. Only symptomatic patients usually receive surgical treatment. Esophageal leakage is one of the most common complications after these procedures. Though in literature, operative management is the preferred treatment for esophageal fistula, conservative approach is described in case of small leaks. We report a case of an operated giant mid-esophageal diverticulum complicated with an esophageal fistula. The patient underwent a surgical treatment and recovered completely.

Laparoscopic staging and radiofrequency of hepatocellular carcinoma in liver ci rrhosis. A "bridge" treatment to liver transplantation

BACKGROUND/AIMS

Surgical resection and liver transplantation are the only curative treatments for hepatocellular carcinoma, although limited to early stage disease. Our objective was to assess a novel operative combination of laparoscopic ultrasound with laparoscopic radiofrequency ablation of small hepatocellular carcinoma in potential candidates to liver transplantation when radiological evaluation is equivocal. We also evaluated the feasibility and efficacy of laparoscopic radiofrequency ablation.

METHODOLOGY

Over a 2-year period, a laparoscopic ultrasound exploration and a laparoscopic radiofrequency ablation was performed in 15 patients (mean age 57+/-5.4 years; male/female 13/2) with hepatocellular carcinoma in liver cirrhosis.

RESULTS

LRFA procedure was completed in all patients and a thermoablation of 36 hepatocellular carcinoma nodules was achieved. Laparoscopic ultrasound identified 12 new malignant lesions (46.1%) undetected by preoperative imaging. Six patients were up-staged as a result of the procedure and 3 were precluded from liver transplantation listing. A complete tumor necrosis was observed in 32 thermoablated nodules (88.8%) via spiral computed tomography 1 month after treatment. Seven patients underwent liver transplantation after a 5.8-month mean interval, and pathological staging of the explants agreed with laparoscopic staging for number/size of hepatocellular carcinoma nodules in all cases. Residual tumor was found in 2/12 (16.6%) thermoablated nodules, in two different liver specimens.

CONCLUSIONS

Laparoscopic ultrasound accurately staged hepatocellular carcinoma in advanced cirrhosis with minimal morbidity and it can be used in potential candidates to liver transplantation. Laparoscopic radiofrequency ablation of hepatocellular carcinoma proved to be a safe and effective technique, representing a valid "bridge" treatment to liver transplantation or an effective palliative option.