C. V. Sansalone

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.

Rapid disappearance of hepatic adenoma after contraceptive withdrawal.

We present the case of a 25-year-old woman who developed a large central liver adenoma after 8 years of continuous oral contraceptive use. The first diagnosis was made by ultrasonography, after a rise in plasmatic gamma-glutamyl-transpeptidase and alkaline phosphatase levels was noted. Withdrawal of the oral contraceptive was followed by shrinkage of the adenoma, with complete disappearance 9 months after the diagnosis. Hepatic adenoma (HA) still presents problems in terms of differential diagnosis and clinical management. There are reports of complete or partial regression of an HA after discontinuation of oral contraceptives, but they are poorly documented. To our knowledge, a patient with such rapid disappearance of a large HA has never been reported.

Is lymphocele in renal transplantation an avoidable complication

BACKGROUND This study evaluated the impact of surgery in the incidence of lymphocele after kidney transplantation (KTx). METHODS A prospective randomized study was conducted during a 6-year period on a group of patients undergoing KTx and operated on by the same surgeon (CVS). A total of 280 patients undergoing KTx were randomly allocated into two groups: (1) group C (control group) was 140 patients who were submitted to KTx with standard technique: implantation of the kidney in the controlateral iliac fossa with vascular anastomoses on the external iliac vessels; and (2) group M (modified technique group) was 140 patients who underwent a modified technique with a cephalad implantation of the graft in the ipsilateral iliac fossa and vascular anastomoses in the common iliac vessels. Both groups were comparable for age, cold ischemia time, incidence of rejection episodes, presence of adult polycystic kidney disease, and source of donor graft. RESULTS Group M showed an incidence of lymphocele production (3 patients, 2.1%) significantly lower than group C (12 patients, 8.5%). Eight patients (1 in group M and 7 in group C) required surgical treatment by peritoneal fenestration. No allograft or recipient was lost as a result of fluid collection but the hospitalization was shorter in group M than in group C. CONCLUSIONS A cephalad implantation of the renal graft in the ipsilateral iliac fossa has been associated with a lower incidence of lymphocele, probably because vascular anastomoses on the common iliac vessels cause less lymphatic derangement than those performed on the external iliac vessels.

Early pancreas retransplantation for vascular thrombosis in simultaneous pancreas-kidney transplants.

Vascular thrombosis is still the leading cause of nonimmunologic, technical pancreatic transplant graft failures and usually occurs in the early postoperative period. Little data exist regarding the issue of pancreas retransplantation although it has been described for chronic rejection in pancreas transplant alone with poor results. From October 1993 to December 1996, 16 patients with type I diabetes mellitus and end-stage renal disease underwent to SPK at our Dept. of General Surgery and Adominal Organ Transplantation. Twelve were males and 4 females with a mean age of 36.8 (range 25 to 56). Therteen had bladder drainage (BD) and 3 enteric drainage (ED). One patient in the BD group and 1 patient in the ED group had vascular thrombosis of their pancreas graft 7 and 3 days after SPK respectively. Both patients presented hematuria, abdominal tenderness, pain and oedema of the ipsilateral lower limb. At operation, hemorragic necrosis involving the whole pancreas with thrombosis of portal vein extended in the external and common iliac veins was seen. Pancreasectomy and throm-bectomy associated to pancreas retransplantion was performed in 1 patient in the same time while in the other, pancreas retransplant was performed 1 day later. The postoperative course was uneventful and both patients were discharged 16 and 23 days p.o. They are alive and well 6 and 11 months with functioning grafts.

Effect of Steroid Withdrawal on Late Immunologic Complications after Liver Transplantation

The goal in longterm follow up of organ-transplanted patients is the best maintenance immunosuppression with the minimum of drug-related side-effects. Surprisingly, despite the presumed lower immunologic potential of the grafted liver when compared to heart and kidney, longterm immunosuppression without steroids is not widely practiced. Concern exists that weaning from steroids may be associated with the occurrence of more acute and chronic rejection episodes. We report herein our experience on 100 patients in a series of 310 liver transplants performed in our institution, who received sequential quadruple drug induction therapy and who were randomly allocated 3 months after transplantation to either longterm cyclosporin (Cya) monotherapy or to longterm bitherapy (cyclosporin and steroids).

Retransplantation of the Liver Graft: Indication and Results in a Single-Center Experience

Retransplantation of the liver (ReOLtx) is an outstanding challenge for both the patient and the surgeon. While acute ReOLTx, often a consequence of a primary graft non-function (PGNF) or a vascular accident, is a simple and rapid operation, the clinical conditions of the patients are generally critical and results of the procedure may be poor. On the other hand, ReOltx performed long after the first grafting, has commonly indications such as chronic rejection or recurrence of the initial disease (viral cirrhosis, PBC and others); in these cases the operation may be very difficult, time-consuming and bloody. Anyway, the results of ReOLTX are often unsatisfying and concern exist upon its wide application.

Second Renal Allograft Transplants. Experience at a Single Institution

Registry data of heart and liver retransplantation have revealed a pattern of patient survival that is significantly worse than results achieved by primary transplantation. To verify the trend of graft survival following renal retransplantation, we analyzed the results of 67 patients who received a second renal graft at Niguarda Hospital, Milan. Between March 1, 1984 and December 31, 1996, 67 second renal transplants (64 from cadaveric and 3 from living related donors) have been performed in 67 adult recipients (male 37) of mean age of 39 years. This series represented 8.5% of the 787 total renal transplants performed at our institution during the same period after the introduction of routine cyclosporine immunosuppression. In 51 (76.1%) of 67 patients, the cause of their primary renal graft failure was rejection (graft failure was defined by patient death or a return to dialysis). Nine of these 51 primary renal grafts were lost within 6 months of transplantation. Forty-nine (73.1%) had good function until after 5 years. The only contraindication to second transplantation was non-compliance with the medical regimen following a primary transplantation. Primary and second renal transplant patients received quadruple drug therapy (cyclosporine, azathioprine, anti-thymocyte globulin, steroids). Episodes of acute rejection were treated with methylprednisone boluses.

Hyperimmune Globulin in the Prevention of Cytomegalovirus Infection: Lack of Efficacy in Kidney Graft Recipients

An open study has been performed in 21 kidney graft recipients (cadaver and LRD, first and further) in order to evaluate the efficacy of anti-Cytomegalovirus (CMV) hyperimmune globulin in preventing CMV infection or reinfection in the first 2 months following a kidney graft.