Split-liver transplantation eliminates the need for living-donor liver transplantation in children with end-stage cholestatic liver disease

BACKGROUND: End-stage cholestatic liver disease (ESCLD) is the main indication for liver replacement in children. Pediatric cadaver-organ-donor shortage has prompted the most important evolutions in the technique of liver transplantation, in particular living-donor liver transplantation (LDLT) and split-liver transplantation (SLT). METHODS: Between November 1997 and June 2001, 127 children with ESCLD were evaluated for liver transplantation, and 124 underwent 138 liver transplantations after a median time of 40 days. Causes of liver disease were congenital biliary atresia (n=96), Alagille's syndrome (n=12), Byler's disease (n=8), and other cholestatic diseases (n=8). RESULTS: Ninety (73%) patients received a split-liver graft, 28 (23%) a whole liver, and 6 (4%) a reduced-size liver. Overall 2- and 4-year patient survival rates were 93% and 91%, respectively; the 2- and 4-year graft-survival rates were 84% and 80%, respectively. In split-liver recipients, 4-year patient and graft-survival rates were 91% and 83%, respectively; these were 93% and 78%, respectively, in whole-liver recipients and 67% and 63%, respectively, in reduced-size liver recipients. Retransplantation rate was 11%, whereas mortality rate was 8%. Overall incidence of vascular and biliary complication were 16% and 27%, respectively. CONCLUSIONS: SLT can provide liver grafts for children with ESCLD with an outcome similar to the one reported following LDLT, eliminating mortality while they are on a transplantation wait list. The need for pediatric LDLT should be reevaluated and programs of SLT strongly encouraged and supported at a national and international level.     

Outpatient laparoscopic cholecystectomy: a reality.

BACKGROUND: The author reports on his personal experience with outpatient laparoscopic cholecystectomy (LC), focusing on the main guidelines for preoperative and postoperative care and operating technique. METHODS: From January 1, 2000 to December 31, 2000, 71 laparoscopic cholecystectomies were performed on outpatients. The patients remained in the outpatient surgery center for 36 hours. In 4 cases, the operation was converted into laparotomy. Twenty patients remained in the hospital and were discharged 5 to 7 days later. Twelve were rehospitalized due to pathologies that could not be treated at home. RESULTS: In all 71 cases, a complete remission of the symptoms occurred, and none of the patients died either during the operation or during the postoperative period. Eighty percent of patients were treated in outpatient surgery centers. CONCLUSIONS: With clear guidelines, LC is a major surgical operation that can be performed in outpatient surgery centers without death or other major complications and with very good remission of symptoms.     

N-acetylcysteine protects against star fruit-induced acute kidney injury

Background: Star fruit (SF) is a popular fruit, commonly cultivated in many tropical countries, that contains large amount of oxalate. Acute oxalate nephropathy and direct renal tubular damage through release of free radicals are the main mechanisms involved in SF-induced acute kidney injury (AKI). The aim of this study was to evaluate the protective effect of N-acetylcysteine (NAC) on SF-induced nephrotoxicity due to its potent antioxidant effect.

Materials and methods: Male Wistar rats received SF juice (4?mL/100?g body weight) by gavage after a 12?h fasting and water deprivation. Fasting and water deprivation continued for 6?h thereafter to warrant juice absorption. Thereafter, animals were allocated to three experimental groups: SF (n?=?6): received tap water; SF?+?NAC (n?=?6): received NAC (4.8?g/L) in drinking water for 48?h after gavage; and Sham (n?=?6): no interventions. After 48?h, inulin clearance studies were performed to determine glomerular filtration rate. In a second series of experiment, rats were housed in metabolic cages for additional assessments.

Results: SF rats showed markedly reduced inulin clearance associated with hyperoxaluria, renal tubular damage, increased oxidative stress and inflammation. NAC treatment ameliorated all these alterations. Under polarized light microscopy, SF rats exhibited intense calcium oxalate birefringence crystals deposition, dilation of renal tubules and tubular epithelial degeneration, which were attenuate by NAC therapy.

Conclusions: Our data show that therapeutic NAC attenuates renal dysfunction in a model of acute oxalate nephropathy following SF ingestion by reducing oxidative stress, oxaluria, and inflammation. This might represent a novel indication of NAC for the treatment of SF-induced AKI.     

Accuracy of core temperature measurement in deep hypothermic circulatory arrest

Deep hypothermia is an effective technique for neuroprotection in cardiac surgery. However, standard body temperature measurement may deviate from actual brain temperature. Therefore, we simultaneously measured brain and core temperatures during neurosurgical interventions in hypothermic circulatory arrest to determine its accuracy. Between 1994 and May 2007, 26 patients (12 female, mean age 46+/-14 years), with complex intracranial aneurysms, underwent resection or clipping applying closed chest cardiopulmonary bypass and hypothermic circulatory arrest via inguinal cannulation. During surgery, temperature probes were positioned in the brain, tympanum, bladder, rectum and pulmonary artery. Mean cardiopulmonary bypass time was 147+/-39 min, mean circulatory arrest time was 28+/-8 min. Brain temperatures were best reflected by bladder and tympanum probes (Pearson's correlation coefficients: bladder=0.83; tympanum=0.80; pulmonary artery=0.63; rectum=0.37; P<0.05). Mean deviations from brain temperature were +0.2+/-2.7 degrees C at the tympanum, -0.8+/-2.6 degrees C in the bladder, -0.7+/-2.6 degrees C in the pulmonary artery and -1.8+/-4.4 degrees C in the rectum. In conclusion, temperature monitoring in the bladder and tympanum reliably reflects brain temperature. Temperature measurements in the pulmonary artery and rectum are less optimal.     

Tracheal agenesis without esophageal fistula: genetic, resuscitative, and pathological issues

An exceptional case of tracheal agenesis with no communication with the esophagus is described. This malformation needs surgical airway approach and is hardly classifiable. We analyzed the literature and our institutional data: this resulted to be the first case of such anatomical variant. Genetic and pathological issues are reviewed: recent genetic data seem to explain this malformation. We also reviewed the available literature about prenatal presentation. Because prenatal diagnosis is difficult to achieve and current guidelines for neonatal resuscitation do not provide any recommendation, the resuscitative team may not be prepared for managing such a case. Usefulness of uncommon resuscitative maneuvers is discussed: a promptly performed surgical tracheotomy is the only mean to ventilate such a baby.     

"Radical but conservative" is the main goal for ultrasonography-guided liver resection: prospective validation of this approach

BACKGROUND: Despite higher blood loss, morbidity, and mortality, rate of major resection is still high in most surgical institutions because of fear of incomplete tumor removal. To verify whether intraoperative ultrasonography (IOUS) minimizes the rate of major hepatectomies while maintaining treatment radicality, we have prospectively validated our policy, based on extensive use of IOUS resection guidance. STUDY DESIGN: Ninety-three consecutive patients with liver tumors were prospectively enrolled. There were 61 men and 32 women with a mean age of 65.6 years. Fifty-nine patients had hepatocellular carcinoma and 34 had colorectal cancer liver metastases. Surgical strategy was based on the relationship between the tumor and intrahepatic vascular structures at IOUS. Rates of major and minor resection, mortality, morbidity, and rate of local recurrences were evaluated. RESULTS: There was no hospital mortality; major morbidity occurred in 2.2% of patients and minor complications in 17%. Six (6.5%) patients required blood transfusion. Major resections (two or more segments) were accomplished in 14 patients (15%), and 5 (5.4%) patients had more than three segments removed. Major vascular invasion was present in 16 patients (17%), and contact without infiltration with major vessels was present in another 16; part of the wall of the inferior vena cava was resected in 1 patient. Surgical clearance was achieved in all patients without local recurrence at a mean followup of 18 months (median 13, range 6 to 52 months). CONCLUSIONS: This study shows that liver operations performed under IOUS guidance are safe and radical and reduce need for major hepatectomies.     

Comparison of Recurrence of Hepatocellular Carcinoma After Resection in Patients with Cirrhosis to Its Occurrence in a Surveilled Cirrhotic Population

The presence of cirrhosis is the only risk factor that is advocated for recurrence of hepatocellular carcinoma (HCC) 2 years after hepatic resection compared with noncirrhotic control subjects; however, data for cohorts of exclusively patients with cirrhosis are lacking. This study was designed to assess risk factors and annual incidence of early (<2 years) and late (>2 years) recurrence after resection of cirrhosis and to compare these findings with those of patients with cirrhosis enrolled in HCC surveillance programs (HCC occurrence). Data from 204 patients with cirrhosis resected for HCC and 150 surveilled for cirrhosis were retrospectively collected and compared using propensity score matching to overcome biases of nonrandomized study. Risk factors for early recurrence (incidence = 21.8%/year) were higher serum alpha-fetoprotein (AFP) levels, poorly differentiated tumor, and presence of microvascular invasion (P < 0.05). Risk factors for both late recurrence (18.4%/year) and HCC occurrence (3.3%/year) were male gender, older age, and higher serum transaminase levels; multiple primary tumors and higher AFP were additional risk factors for late recurrence and HCC occurrence respectively (P < 0.05). After propensity adjustment, resected patients with less than two risk factors for late recurrence showed an annual incidence of HCC (6.2%/year) similar to that of surveilled patients with ≥2 risk factors (5.8%/year; P = 0.898). Early and late recurrence of HCC for patients with cirrhosis after resection have distinct risk factors. Annual incidence of HCC 2 years or more after resection may be similar to that of general patients because the same risk factors are involved; assessment of these characteristics could be useful in tailoring clinical management.     

CA19-9 serum levels in obstructive jaundice: clinical value in benign and malignant conditions

Background

Obstructive jaundice is frequently associated with false CA19-9 elevation in benign conditions. The diagnostic accuracy of this tumor marker was evaluated in the present longitudinal study.

Methods

In 128 patients admitted for obstructive jaundice (87 with pancreato-biliary malignancy and 41 benign disease) serum CA19-9 was measured. Statistical analysis of marker levels obtained before and after endoscopic biliary drainage was performed in 60 patients.

Results

Elevated CA19-9 levels (>37 U/mL) were found in 61% of benign cases and 86% of malignancies. After biliary drainage, decrease of serum CA19-9 was observed in 19 of 38 malignant cases and in almost all benign cases (Wilcoxon matched pairs test: P = .207 and P <.001, respectively). Receiver operating characteristic (ROC) analysis identified a cut-off value of 90 U/mL to be associated with improved diagnostic accuracy after biliary drainage (sensitivity 61%, specificity 95%).

Conclusions

In the presence of successfully drained obstructive jaundice, CA19-9 serum levels that remain unchanged or measure more than 90 U/mL are strongly indicative of a malignant cause of obstruction. However, the real clinical utility of this marker remains controversial.     

EULID Project: European Living Donation and Public Health

The choice of transplantation from a living donor offers advantages over a deceased donor. However, it also carries disadvantages related to donor risks in terms of health and safety. Furthermore, there are several controversial ethical aspects to be taken into account. Several national and international institutions and the scientific community have stated standards that have great influence on professional codes and legislations. Living organ donation and transplantation are to some extent regulated by parliamentary acts in most European countries. It is necessary to take a step forward to develop a legal framework to regulate all of these processes to guarantee the quality and to prevent illegal and nonethical practices. It is also necessary to develop and implement living donor protection practices not only in terms of physical health, but also to minimize potential impacts on the psychological, social, and economic spheres. Finally, an additional effort should be made to create a database model with recommendations for registration practices as part of the standardized follow-up care for the living donor. The European Living Donation (EULID) project's (http://www.eulivingdonor.eu/) main objective was to contribute to a European consensus to set standards and recommendations about legal, ethical, and living donor protection practices to guarantee the health and safety of living donors.