G. Colella

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.

Liver transplantation for hepatocellular carcinoma: prognostic factors associated long-term survival

Abstract  Between December 1985 and February 1995, 260 orthotopic liver transplantations (OLTX) were performed on 238 patients at Niguarda Hospital. Sixty‐three patients had hepatocellular carcinoma (HCC); in 13 of the patients HCC was incidental. All patients had negative lymph nodes. According to the Child classification, 13 patients were Child A, 30 Child B, and 18 Child C. According to the TNM classification, 11 patients were stage I, 22 stage II, 15 stage III, and 15 stage IVa. Pre‐OLTX chemoem‐bolization was performed on 25 patients. The perioperative mortality rate was 27 % (17 patients). Overall survival and disease‐free actuarial survival rates at 1, 3, and 5 years were 94 %, 76 %, 76 %, and 83 %, 75 %, 75 %, respectively. Survival curves were compared for 16 different variables. No difference was observed for all parameters analyzed except tumor site, TNM stage, pre‐OLTX AFP levels and vascular infiltration. These results seem to demonstrate that the OLTX for un‐resectable HCC can be considered in specifically selected cases as the treatment of choice. An adequate tumor staging is also necessary for a better patient selection in order to increase survival.

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.