Ruben Canelo

A novel management strategy of steroid-free immunosuppression after liver transplantation: efficacy and safety of tacrolimus and mycophenolate mofetil.

Background. Corticosteroids have been used traditionally for immunosuppression after solid organ transplantation. The variety of modern immunosuppressive agents offers the chance to replace drugs with an unfavorable risk-benefit ratio. The objective of this prospective pilot study was to investigate a novel steroid-free immunosuppressive regimen after clinical liver transplantation. Methods. 30 adult liver graft recipients were included in an intent-to-treat analysis. Dual induction immunosuppression consisted of tacrolimus and mycophenolate mofetil. Prophylactic steroids were not given. Efficacy and safety parameters analyzed were patient and graft survival, incidence and severity of rejection, and adverse events in correlation to immunosuppressive drug levels. Results. Patient and graft survival at 2 years was 86.7 and 83.9%, respectively. Acute rejection occurred in 26.2%, and was associated with subtherapeutic tacrolimus blood levels and diarrhea. All rejections were completely reversible by temporary addition of steroids. Acute renal failure was seen in 10/30 patients, and was related to high tacrolimus blood levels together with primary liver graft dysfunction. 43% of all patients never received any steroids, and 73% were on a steroid-free maintenance regimen. Conclusions. These results confirm that corticosteroids can be completely avoided from the beginning after liver transplantation. Double drug immunosuppression with tacrolimus and mycophenolate mofetil is effective and safe in terms of patient and graft survival as well as incidence and severity of rejection. In order to avoid under- or over-immunosuppression, which may be caused by impaired absorption or metabolism, close drug monitoring is advised.

Liver resection with bipolar radiofrequency device: Habib™ 4X

BACKGROUND Intraoperative blood loss has been shown to be an important factor correlating with morbidity and mortality in liver surgery. In spite of the technological advances in hepatic parenchymal transection devices, bleeding remains the single most important complication of liver surgery. The role of radiofrequency (RF) in liver surgery has been expanded from tumour ablation to major hepatic resections in the last decade. Habib 4X, a new bipolar RF device designed specifically for liver resection is described here. METHODS Habib 4X is a bipolar, handheld, disposable RF device and consists of two pairs of opposing electrodes which is introduced perpendicularly into the liver, along the intended transection line. It produces controlled RF energy between the electrodes and the heat produced seals even major biliary and blood vessels and enables resection of the liver parenchyma with a scalpel without blood loss or biliary leak. RESULTS Three hundred and eleven patients underwent 384 liver resections from January 2002 to October 2007 with this device. There were 109 major resections and none of the patients had vascular inflow occlusion (Pringles manoeuvre). Mean intraoperative blood loss was 305 ml (range 0-4300) ml, with less than 5% (n=18) rate of transfusion. CONCLUSION Habib 4X is an additional device for hepatobiliary surgeons to perform liver resections with minimal blood loss and low morbidity and mortality rates.

Treatment of Hepatic Metastases from Gastroenteropancreatic Neuroendocrine Tumors: Role of Liver Transplantation

Abstract. The role of liver transplantation in malignancy has been discussed, but controversially, over the past two decades. This is particularly true for hepatic metastases from neuroendocrine tumors, which have a wide variety of primary tumor localizations, morphologic types, functional activities, and clinical presentations. Despite generally slow tumor progression, the prognosis is often unpredictable. Total hepatectomy and liver replacement has been offered primarily to patients with nonresectable metastases and symptomatic disease. The results from retrospective single and multicentric analyses show that most liver recipients experience significant palliation despite tumor recurrence, and in some patients long-term cure can be achieved. The existing data emphasize the importance of proper selection and timing for this approach.

Concordant F-18 FDG PET and Y-90 Bremsstrahlung scans depict selective delivery of Y-90-microspheres to liver tumors: confirmation with histopathology.

Selective Internal Radiation Therapy using yttrium-90 (Y-90) microspheres is a novel method for the treatment of advanced liver cancer. The procedure involves intrahepatic arterial delivery of the Y-90 microspheres. Since hepatic tumors derive their blood supply mainly from the hepatic arteries, it is assumed that the microspheres will be preferentially delivered to tumor cells. However, this has not been confirmed at histology. We report a case of hepatic metastasis from an unknown primary, where treatment with Y-90 microspheres was the only available option due to inoperability and low tolerance to chemotherapy. Pretherapy F-18 FDG-PET scan defined the distribution of the active tumor within the liver. Following the injection of Y-90 microspheres, Bremsstrahlung imaging showed uptake only in the F-18 FDG-PET-defined tumor area. Post therapy debulking surgery was performed and histopathology of tumor samples confirmed the preferential distribution of the injected microspheres in the hepatic tumor circulation with very little in the healthy liver tissue. The case confirms the preferential blood flow to hepatic tumors as depicted by the distribution of Y-90 microspheres injected directly in the hepatic arteries. It also demonstrates that concordance between F-18 FDG-PET and Y-90 Bremsstrahlung scans can be a useful clue to the in vivo distribution of microspheres.

Situs inversus of donor or recipient in liver transplantation

Abstract Situs inversus is a rare anatomical abnormality that is often associated with multiple, complex malformations. In the past, patients with situs inversus were considered unsuitable candidates for transplantation or organ donation because associated visceral, and especially vascular, anomalies pose special technical difficulties. Recently, several cases of successful liver transplantation in recipients with situs inversus have been published using modified surgical techniques. This report reviews the literature and describes our own experience, including two liver graft recipients with complete and incomplete situs inversus, and one patient who underwent successful transplantation using a liver from a donor with situs inversus.

Chirurgische Therapie benigner Lebertumoren

Zum ThemaDurch Sonographie, Farb-Doppler-Technik, Computer- und Magnetresonanztomographie sowie szintigraphische Methoden gelingt in aller Regel eine gute Differenzierung der häufigsten benignen Lebertumoren. Ergänzt wird diese natürlich durch klinische und humorale Untersuchung unter Einschluß von Tumormarkern, um die Verdachtsdiagnose maligne oder benigne zu untermauern. Die Biopsie sollte weitgehend vermieden werden, da die meistens sichere Diagnostik eindeutig nichtmaligner Strukturen durch die genannten Verfahren möglich ist und malignitätsverdächtige Strukturen ohnehin eine Operation notwendig machen, sofern der Zustand des Patienten dies erlaubt.In dieser Arbeit werden nur die benignen soliden Lebertumoren behandelt, nicht die (poly-)zystischen, parasitär zystischen Lebererkrankungen und Abszesse.

Liver and pancreatic diseases management

1. Preface 2. Isolated Hepatic Perfusion Treating Unresectable Liver Metastases: Jeffry M. Farma, James F Pingpank, H Richard Alexander 3. Management of Common Bile Duct Stones in the Era of Laparoscopic Surgery: Claude Smadja, Nada Helmy, Alessui Carloni 4. Split-Liver Transplantation: Hans J Schlitt, Martin Ross, Aiman Obed 5. Surgery and Chemotherapy combined for Colorectal Liver Metastasis: Bernard Nordlinger 6. Radiofrequency Assisted Liver Resection: The Habibs Technique: Long R Jiao, Giussepe Navarra, Jean Christopher Weber, Roman Havlic, Joanna P Nicholls, Nagy Habib 7. Radiofrequency Assisted Liver Resection: Experience of Italian Hepatic Surgery Unit: Riccardo Pellicci, Andrea Percivale, Michele Pittaluga, Massimo Pasqualini, Alberto Profeti, Alessandro Paroldi 8. Hepatic Surgery for Metastatic Gastrointestinal Neuroendocrine Tunours: Florencia Que, Juan M. Sarmiento, David M. Nagorney 9. Electrodes and Multiple Electrodes System for Radiofrequency Ablation: A Proposal for updated Terminology: Stefaan Mulier, Yi Miao, Peter Mulier, Benoit Dupas, Philippe Pereira, Thierry de Baere, Riccardo Lencioni, Raymond Leveille, Guy Marchal, Luch Michel, Yicheng Ni 10. Bloodless Liver Resection Technique Miroslav Milicevic 11. Islet Cell Allotransplantation. Development of a Clinical Programme in West London: Vassilios E Papalois 12. Whole Organ Pancreas Transplantation: Nadey S Hakim 13. Pancreatic Cancer. Are there New Treatment Options?: Juergen Tepel, Holger Kalthoff 14. Current Practiced in Pancreatic Surgery: Philippe Bachellier, John Tierris, Jean C Weber

De-novo-Lebertumoren nach protokavalem Shunt bei Budd-Chiari-Syndrom

The Budd-Chiari syndrome is one cause of portal hypertension with multiple etiology and different therapeutic interventional strategies. We report on a 23-year-old female patient who developed de novo liver tumors 33 months after portocaval shunting for acute Budd-Chiari syndrome.

Akutes Leberversagen und Vorgehen bei Notfallindikationen

Das Management von Patienten mit akutem Leberversagen und von anderen Notfallsituationen erfordert ein hohes Maβ an klinischer Erfahrung und interdisziplinarer Zusammenarbeit. Entscheidend fur die Ges

Challenges in Colorectal Cancer

Edited by John H Scholefield, Herand Abcarian, Axel Grothey, Tim Maughan. Oxford: Blackwell Publishing, 2006, £69.50, pp 296. ISBN 9781405127066. Colorectal adenocarcinoma (colorectal cancer; CRC) is the third most common type of cancer and the fourth most frequent cause of death due to cancer worldwide. Almost 1 million new cases of CRC occur annually, amounting to 492 000 related deaths. In developed countries, it is the second most common type of tumour, with a lifetime risk of …