A. Corti

Hepatocellular carcinoma: comparison between liver transplantation, resective surgery, ethanol injection, and chemoembolization

Abstract Between January 1989 and June 1997, 533 patients (423 male, 110 female, mean age 61 years, range 22–89 years) with hepatocellular carcinoma (HCC) were observed at our center. We report on 419 patients retrospectively compared for different treatments: liver transplantation (LT; 55 patients), resective surgery (RS; 41 patients), transarterial chemoembolization (TACE; 171 patients) and percutaneous ethanol injection (PEI; 152 patients). The 3‐ and 5‐year actuarial survival rates were, respectively, 72% and 68% for LT, 64 and 44% for RS, 54 and 36% for PEI, and 32 and 22% for TACE. Survival curves were compared for sex, age, tumor characteristics, alphafetoprotein level, Child class, and etiology of cirrhosis. All patient‐related characteristics examined (sex, age) are not significantly related to patient survival. Tumor‐related variables and associated liver disease variables significantly conditioned survival in relation to different treatments. LT seems to be the treatment of choice for monofocal HCC less then 5 cm in diameter and in selected cases of plurifocal HCC.

Lactate blood levels in the perioperative period of orthotopic liver transplantation

To investigate whether early postoperative changes in blood lactate concentration indicate the functional recovery of the newly grafted liver, changes in oxygen supply, oxygen consumption, acid-base equilibrium, and blood lactate concentrations were prospectively studied in a group of 53 postnecrotic cirrhotic patients during the various phases of orthotopic liver transplantation (preanhepatic, anhepatic, neohepatic) and for the first 48 h following reperfusion. The patients were divided into two groups according to the quality of the early graft function, as indicated by alanine aminotransferase, bile flow, and prothrombin activity: group A (49 patients), good immediate graft function and group B (4 patients), immediate graft non-function. Lactate levels rose in the same manner during the preanhepatic and anhepatic stages and peaked after revascularization of the graft. Following reperfusion, however, distinctly different blood lactate profiles were recorded in the two groups of patients. A fall in lactate concentration was recorded in group A patients, whereas a continuous rise occurred in group B patients: the difference becoming significant by the end of surgery (P<-0.05). During the first 48 h following revascularization of the graft, opposite trends in lactate concentration, bile flow, alanine aminotransferase, and prothrombin activity were evident in the two groups of patients: 24 h after reperfusion, lactate levels were below 2 mmol/1 in 47 of 49 patients from group A, while they plateaued above 4 mmol/1 in all patients from group B. Group A patients had lower alanine aminotransferase levels (P<-0.001), higher prothrombin activity, (P<-0.01), and greater bile flow (P<-0.02). If validated in larger series, the blood lactate profile, probably more than the absolute level, appears to be a useful indicator of the early recovery of liver metabolic capacities in the immediate postoperative period of orthotopic liver transplantation.

Changes in circulating levels of atrial natriuretic factor (ANF) during orthotopic liver transplantation in humans.

Abstract Atrial natriuretic factor (ANF) is a 28 amino acid peptide secreted by the atrial cardiocytes. Clearance is via the lung (50%) and the liver (25%). The main stimulus to ANF secretion is atrial distension but vasoconstrictors, sympathetic stimulation, catecolamines and tachycardia are able to enhance its circulating blood levels. ANF blood concentrations were measured during orthotopic liver transplantation in six postnecrotic cirrhotic patients. Significant increases in ANF blood levels occurred at the end of the anhepatic phase (P≤ 0.02 vs baseline) associated with low cardiac filling pressures (P≤ 0.02 vs baseline) and increased systemic vascular resistances (P≤ 0.02 vs preanhepatic phase). Aldosterone blood levels showed a similar behaviour, increasing significantly (P≥ 0.001 vs baseline) at the end of the anhepatic phase. ANF fell after reperfusion of the graft and returned towards baseline values at the end of the procedure. Since most of the total body clearance of ANF is performed by the lungs, its sharp increase at the end of the anhepatic phase could be considered a counterregulatory response to vasoconstricting stimulation and to fluid‐paring mechanisms in the presence of relative hypovolaemia. Its decrease after reperfusion could be related to volume normalization and partly to the enhanced clearance performed by the newly grafted liver.

Hypotension After Pancreatic Reperfusion During Combined Kidney- Pancreas Transplantation

OMBINED kidney‐pancreas transplantation (KPTx) is an accepted and ever-increasing therapeutic option for patients suffering for diabetes mellitus (DM) type I who had developed end-stage renal failure (ESRF). Two of the main goals of this surgical procedure are capable of improving significantly the quality of life of these subjects: (1) recovery of renal function; (2) euglicemic state without insulin supplementation. 1 Correction of the metabolic abnormalities could prevent (or delay) the onset of severe secondary complications. Patients considered for combined KPTx manifest most of the multisystem dysfunctions associated with both diseases; generally, they are in poor medical condition and more prone to develop perioperative complications. Arterial hypertension and preoperative cardiac dysfunction secondary to autonomic neuropathy and microvascular changes are frequent findings in these patients and could be responsible for the cardiovascular complications occurring during surgery or in the immediate postoperative period: silent coronary artery disease has been reported in 20% to 40% of the candidates and hypertensive cardiomyopathy is a frequent echocardiographic finding in individuals affected by ESRF. 2 Because preoperative cardiovascular impairment has been associated with high morbidity and mortality and decreased graft survival, perioperative hemodynamic stability has been considered essential for the early functional recovery of the grafts and for the containment of postoperative complications. 3 Recent advances in invasive hemodynamic monitoring and anesthetic techniques made it possible to preserve or improve cardiovascular homeostasis. However, studies dealing with the hemodynamic profile during KPTx are scarce. In this paper we will describe the cardiovascular changes occurring during the various phases of surgery, specifically addressing the problem of hypotension following pancreatic reperfusion. 3 PATIENTS AND METHODS Our series includes 17 patients (mean age, 32 6 17 years) admitted to combined KPTx for ESRF and severe DM type 1. Eighty percent of the patients were affected by severe hypertension; one had ejection fraction lower than 40%. Heart rate and rhythm, pulse oxymetry, right atrial (RAP), and radial artery pressures were continuously monitored in all the cases. Right heart catheterization with a modified Swan‐Ganz catheter (SG cath Intellicath, Baxter) for complete invasive hemodynamic monitoring (pulmonary capillary wedge pressure [PWP] and cardiac output [CO] for continuous monitoring) was used in eight patients. Systemic vascular resistance (SVR, dynes sec 21 /cm 25 ) was calculated according to standard formulae. Hemodynamic data reported in this paper were recorded after the induction of the anesthesia (baseline, A), 5 minutes before (pre-pancreas reperfusion, B) and 2 minutes after pancreas reperfusion (post-pancreas reperfusion, C), 2 minutes after renal reperfusion (post-kidney reperfusion, D), and at the end of surgery (end of surgery, E). Severe arterial hypotension following pancreas reperfusion was considered mean arterial pressure (MAP) less than 70 mm Hg or less than 70% of the baseline values. General anesthesia and mechanical ventilation were used in all the patients: anesthesia was induced with thiopental and maintained with fentanyl and isoflurane (0.8 to 1.2% in air/O2 mixture 50%); atracurium besylate was used for muscle relaxation. Data are presented as mean 6 SD. Statistical analysis was performed using ANOVA. A P value # .05 was considered statistically significant.

Problematiche anestesiologiche nei pazienti sottoposti a trapianto di organo solido

Riassunto Il notevole miglioramento dei risultati e l’aumento della sopravvivenza ottenuti negli ultimi dieci anni nei trapianti di organi solidi portano un sempre maggior numero di soggetti trapiantati a essere candidati a interventi chirurgici in elezione, urgenza o emergenza. Complicanze legate a patologia vascolare arteriosa, patologie a carico di organi viscerali oppure l’insorgenza di tumori de novo obbligano non solo i Centri Trapianti di riferimento, ma anche ospedali in cui non si svolge attivita di trapianto, a occuparsi di questi pazienti. In questo capitolo verranno presi in considerazione i problemi fondamentali che anestesisti e intensivisti potrebbero trovarsi ad affrontare nel periodo perioperatorio di questo particolarissimo paziente. Verranno prese in considerazione sia le modificazioni della funzione dell’organo una volta trapiantato sia le modificazioni del profilo fisiologico del paziente dopo il trapianto. Su questa base saranno discusse sia le problematiche strettamente anestesiologiche (scelta della tecnica anestesiologica e dei farmaci e analisi delle potenziali interferenze farmacologiche) che quelle, piu ampie, legate alla immunosoppressione e al rischio infettivo. Il contatto con il Centro Trapianti di riferimento resta comunque un passo fondamentale e irrinunciabile nella complessa e affascinante gestione clinica di questi pazienti.

Fungal infections in the ICU

Data collected over the past 10–20 years clearly show that invasive fungal infections, far from being observed in immunocompromised hosts only, are increasingly recognised as a growing problem in critically ill nonimmunocompromised patients and in subjects undergoing major surgical procedures [1, 2, 3]. While Candida spp. are the most common cause of severe fungal infections in the ICU, mould infections are so far rare, but the problem is rapidly rising due to the increased spectrum of patients at risk for aspergillar infections [4]. According to Vanderwoude [5], this particular group of patients has recently been categorised into different risk classes: high risk (allogeneic bone marrow-transplanted patients, neutropenic and haematological patients); intermediate risk (autologous bone marrow-transplanted patients, subjects suffering from malnutrition, under corticosteroid therapy, with diabetes or underlying pulmonary diseases) and low risk (patients suffering for cystic fibrosis and connective tissue disease). Cases of invasive pulmonary aspergillosis have been reported in apparently nonimmunocompromised COPD patients [5].