Autologous blood transfusion in patients with hepatocellular carcinoma undergoing hepatectomy

BACKGROUND: Homologous blood transfusion (HBT) has the risk of an immunosuppressive effect and may adversely affect the prognosis of patients with carcinomas. Autologous blood transfusion (ABT) has not yet become a standard procedure in gastroenteric cancer surgery. We investigated the usefulness and problems of ABT combined with the use of recombinant human erythropoietin (rh-EPO). METHODS: An evaluation of autologous blood transfusion (ABT) combined with recombinant human erythropoietin (rh-EPO) treatment was conducted in 46 patients with hepatocellular carcinoma undergoing hepatectomy. Preoperative autologous blood donation (ABD) was accomplished for 25 of the 46 patients. The preoperative changes in hemoglobin and hematocrit in relation to route of administration of erythropoietin were studied. In addition, intraoperative blood requirements and the postoperative complications for patients who predonated were compared with those of patients who underwent surgery without autologous predonation. RESULTS: The proportion of patients not requiring additional homologous blood transfusions (HBT) during operation was significantly higher in the ABD group than in the non-ABD group (88% versus 38%). The incidence of postoperative complications was significantly higher in patients receiving HBT than in nontransfused patients and in those receiving ABT. CONCLUSIONS: Preoperative autologous blood donation in combination with rh-EPO therapy markedly reduced the requirement for homologous blood transfusion during surgery in patients with hepatocellular carcinoma having hepatectomy.     

Factors influencing arterial oxygenation early after bidirectional cavopulmonary shunt without additional sources of pulmonary blood flow

OBJECTIVES: Although the arterial oxygen saturation after bidirectional cavopulmonary shunting should theoretically be homogeneous if additional pulmonary flow is obliterated, the arterial oxygen saturation has been found to vary in clinical practice. Knowledge of the preoperative and operative determinants of arterial oxygen saturation early after bidirectional cavopulmonary shunting may lead to a better understanding of this unique physiology. METHODS: Thirty-five patients who underwent bidirectional cavopulmonary shunting with obliteration of additional pulmonary flow were included in this study. The arterial oxygen saturation was determined at the 5 time points over a 48-hour period. Multivariable regression analysis was used to identify the independent predictors of the arterial oxygen saturation. RESULTS: No significant interval changes occurred in the arterial oxygen saturation during the 48 hours after bidirectional cavopulmonary shunting, which ranged from 61.6% to 95.6%. There was a significant inverse correlation between the postoperative superior vena cava pressure and the arterial oxygen saturation (P =.003). A low arterial oxygen saturation early after bidirectional cavopulmonary shunting was a predictor of mortality or exclusion from univentricular repair within 24 months (P =.012, odds ratio = 1.14). Of 11 factors identified by univariable analysis, multiple regression analysis indicated that age less than 8 months at the time of shunting (P <.0001) and ventricular volume overload (P =. 002) predicted a lower arterial oxygen saturation after bidirectional cavopulmonary shunting. CONCLUSIONS: Even without additional sources of pulmonary blood flow, several preoperative factors, including younger age and severe ventricular volume overload, predicted a decrease in the arterial oxygen saturation early after bidirectional cavopulmonary shunting. This, in turn, predicted poor outcome during 2 years of follow-up.     

Redo without transfusion in a patient with idiopathic thrombocytopenic purpura

Mitral valve replacement was able to be carried out at redo operation requiring neither allogeneic platelet nor blood transfusion in a patient with idiopathic thrombocytopenic purpura, by means of preoperative high-dose intravenous gamma-globulin, autologous blood predonation, use of a centrifugal pump, heparin-coated extracorporeal circuits, and simultaneous splenectomy.     

Anesthesia protocols for early vitrectomy in former preterm infants diagnosed with aggressive posterior retinopathy of prematurity

Aggressive posterior retinopathy of prematurity (ROP) can, if left untreated, rapidly progress to total retinal detachment within 1–2 weeks. Early surgical intervention with vitrectomy has been attempted to treat and prevent further retinal detachment. We investigated the anesthetic management of 29 infants with aggressive posterior ROP undergoing early vitrectomy. Postmenstrual age at surgery ranged from 35 to 47 weeks (median 41). Weight ranged from 1408 to 3478 g (median 1875). All infants underwent general anesthesia with fentanyl and sevoflurane. Mean surgical and anesthetic times were 88.6 and 143.6 min, respectively. In two patients, vitrectomy was postponed for one week due to enteric perforation in one patient and meningitis in the other, because the anticipated perioperative risk was deemed high. There were no intraoperative complications, except in one patient who developed pulmonary edema following upper airway obstruction. All patients survived to be discharged from NICU or transferred to the referring hospital. In all cases, complete or partial retinal reattachment was successfully achieved. Early vitrectomy for aggressive posterior ROP may be effective despite associated perioperative risks. As this condition progresses rapidly, prompt preoperative organization, including anesthetic planning, is important and useful. Anesthesiologists can play an important role in the perioperative management of such high-risk infants.     

Long-term survival after resection of mass-forming type intrahepatic cholangiocarcinoma directly infiltrating the transverse colon and sequential brain metastasis: Report of a case

MUC1 expression in cholangiocarcinoma is considered to be correlated with patient survival. We report a case of mass-forming type intrahepatic cholangiocarcinoma (ICC) with direct infiltration of the transverse colon and sequential brain metastasis. The patient was treated by curative right hepatectomy with right hemicolectomy followed by resection of the brain metastasis; there has been no evidence of recurrence in the 7 years since the hepatic resection. Thus, surgical resection may improve the prognosis of ICC involving the adjacent organs, even with brain metastasis. Immunohistochemical staining was performed for MUC1, MUC2, and MUC5AC. Although MUC1 expression was found in the liver tumor and metastatic brain tumor, the correlation between MUC1 expression and the prognosis of this patient was unclear. To clarify the correlation between immunohistochemical characteristics and prognosis, further studies on a greater number of cases of long-term survival of mass-forming type ICC are needed.     

Role of luminal Ca2+ on normal and damaged gastric mucosa in the rat

Influence of luminal Ca²⁺ on the integrity of normal mucosa and recovery of damaged mucosa in anesthetized rat stomachs was studied using a perfusion system. Changes in the mucosal integrity were monitored by measuring transmucosal potential difference (PD) and luminal pH. EDTA, a Ca²⁺ chelator, dose-dependently reduced PD and increased luminal pH. Five mM Ca²⁺ (CaCl₂) alone produced no changes in either PD and luminal pH, but the PD which was reduced by 250 mM EDTA was significantly recovered. Ethanol or NaCl concentration-dependently reduced PD, but gradually reverted to baseline levels. While 5 mM Ca²⁺ or 5 mM EDTA did not influence the reduction in PD with 50% ethanol or 1 M NaCl, these agents either enhanced or delayed the recovery processes in reduced PD, respectively. Five mM Ca²⁺ enhanced the recovery of PD which was reduced by 50% ethanol plus 5 mM EDTA. Gastric damage induced by 50% ethanol plus 5 mM EDTA was much more severe than that induced by 50% ethanol alone or 50% ethanol plus 5 mM Ca²⁺. Both 50% ethanol and 1 M NaCl significantly increased Ca²⁺ contents in the gastric lumen. Luminal Ca²⁺ appears to play an important role in maintaining mucosal integrity, under normal physiological conditions, and in accelerating the recovery process of damaged mucosa in rat stomachs.     

Significance of low-level DSA detected by solid-phase assay in association with acute and chronic antibody-mediated rejection

We sought to clarify the controversial issue of whether detecting low‐level anti‐donor‐specific HLA antibody (HLA‐DSA) by single‐antigen flow‐bead assay (SAFB) may have a potential role in reducing acute and chronic antibody‐mediated rejection (AMR). We retrospectively studied the preoperative serum of ABO‐compatible living kidney transplantation recipients transplanted between 2001 and 2004 by SAFB using a Luminex platform. HLA‐DSA was detected only by SAFB in 24 patients, although all of them showed negative T‐cell and B‐cell complement‐dependent cytotoxicity (CDC) crossmatches. The HLA‐DSA patients went on to have surprisingly high levels of acute and chronic AMR despite being only weakly sensitized (acute AMR, 33.3%; chronic AMR, 41.7%). After 2005, we implemented SAFB routinely and any patient having a positive HLA‐DSA was considered to be a desensitization candidate. The 52 patients found to have HLA‐DSA underwent kidney transplantation after prior treatment with a single dose of rituximab (RIT) and three or four sessions of double‐filtration plasmapheresis (DFPP) in addition to regimens commonly used between 2001 and 2004. After 2005, there was a significant reduction in the occurrence of acute and chronic AMR (acute AMR, 4.7%, P < 0.001; chronic AMR, 4.7%, P < 0.001). The 5‐year graft survival rate also improved after implementing SAFB (83.3–98.1%, P = 0.032). The RIT/DFPP‐induction protocol may improve graft survival even in patients with low‐level DSA.     

Use of candesartan cilexetil decreases proteinuria in renal transplant patients with chronic allograft dysfunction

BACKGROUND: Posttransplant proteinuria and hypertension are difficult to treat after renal transplantation. Therefore, we examined whether candesartan cilexetil is effective in reducing urinary protein excretion or in controlling hypertension in patients with renal allograft dysfunction. METHODS: Sixty-two renal transplant recipients with proteinuria were enrolled in this study. They underwent kidney transplantation under cyclosporine or tacrolimus immunosuppression between February 1983 and December 1998. Causes of proteinuria were chronic rejection in 28, glomerulonephritis in 16, cyclosporine or tacrolimus nephrotoxicity in 9, and unknown in 9 recipients. The dose of candesartan cilexetil ranged from 4 to 12 mg/day. Eleven patients with proteinuria who had not been treated with candesartan cilexetil constituted a matched control population. RESULTS: Hypertension was well controlled by administration of candesartan cilexetil. Both systolic blood pressure and diastolic blood pressure significantly decreased from 141.7+/-14.8 mm Hg to 118.7+/-11.9 mm Hg and 121.2+/-11.6 mm Hg, and from 89.0+/-13.0 mm Hg to 72.0+/-10.4 mm Hg and 74.9+/-9.4 mm Hg, at 2 months and 1 year after administration, respectively. Urinary protein excretion was reduced from 0.93+/-1.2 g/day to 0.34+/-0.7 g/day and 0.43+/-1.2 g/day at 2 months and 1 year after administration, respectively. The levels of creatinine clearance were 55.7+/-28.9 mL/min before treatment, 50.9+/-24.8 mL/min at 2 months, and 52.6+/-24.8 mL/min at 1 year after treatment, respectively. There was no clinically significant difference between them. Regarding the calcineurin inhibitor levels, there was no significant difference between the levels before and 1 year after treatment. There was a significant difference in all examinations (systolic blood pressure, diastolic blood pressure, proteinuria, and renal function) between the patients with and without candesartan at 1 year after treatment. No significant adverse effects occurred. CONCLUSIONS: Candesartan cilexetil can effectively control hypertension and proteinuria without deterioration in renal allograft function. These data suggest that treatment with candesartan cilexetil may be useful for maintaining long-term renal allograft function.     

Long-term outcome of hand-assisted laparoscopic radical nephrectomy for localized stage T1/T2 renal-cell carcinoma

PURPOSE: To evaluate the efficacy of hand-assisted laparoscopic radical nephrectomy (HALRN) in patients with localized stage T(1)/T(2) renal-cell carcinoma, we analyzed the clinical results of our patients treated in this way. PATIENTS AND METHODS: From March 1999 to March 2003, a total of 96 patients aged 28 to 86 years (mean 61 years) with clinical stage T(1)/T(2)N(0)M(0), pathologically confirmed renal-cell carcinoma underwent HALRN. The outcomes were compared with those of open radical nephrectomy, which was performed in 86 patients from November 1991 to February 1999 in our institution. Kaplan-Meier analysis was used to analyze survival. RESULTS: Ten patients (10.4%) had perioperative complications. During a mean follow-up of 25 months (range 6-54 months), no patients died of the cancer, although three patients had metastatic disease. The 4-year disease- free and overall survival rates were 88% and 100%, respectively. Seventy-eight patients who underwent open radical nephrectomy were followed for 38 to 156 months (median 86 months). Seventy-three survived without any recurrent disease, five survived with metastasis, and no patient died of metastatic disease. The 4-year disease-free and overall survival rates were 93% and 100%, respectively. CONCLUSIONS: Hand-assisted laparoscopic surgical management of T(1)/T(2) renal-cell carcinoma is feasible and safe. At our institution, HALRN confers long-term oncologic effectiveness equivalent to that of open radical nephrectomy.     

Cytomegalovirus infection following renal transplantation in patients administered low-dose rituximab induction therapy

Anti-CD20 antibody (rituximab) is recently being used as a B cell-depleting agent in renal transplantation (RTx). However, the incidence of infectious complications associated with rituximab therapy remains uncertain. We evaluated the incidence of cytomegalovirus (CMV) infection associated with rituximab therapy in RTx. A total of 83 patients were enrolled. The immunosuppressive regimen consisted of tacrolimus or cyclosporin, mycophenolate mofetil, methylprednisolone and basiliximab. In 54 patients, only one dose of rituximab (200 or 500 mg/kg body weight) was given before RTx. A total of 25 of 43 (58.1%) recipients who were CMV seropositive prior to RTx and who received rituximab induction therapy developed CMV infection, compared to 18 of 24 (75%) CMV seropositive recipients who did not receive rituximab therapy ( P  = 0.1676). A total of 8 of 11 patients who were CMV seronegative prior to RTx and who received rituximab developed CMV infection. However, CMV seroconversion was seen in all 8 of these infected patients. Low-dose rituximab induction therapy in renal transplant recipients appears to have no influence on the incidence of CMV infection and CMV seroconversion. However, we have to consider anti-CMV prophylaxis therapy, because of high incidents of CMV infection, especially for CMV seronegative recipients who received rituximab.