The oncological and obstetric results of radical trachelectomy as a fertility-sparing therapy in early-stage cervical cancer patients.

PURPOSE: This study explored the oncological and obstetric results of radical trachelectomy (RT) in early-stage cervical cancer patients. METHODS: A retrospective analysis was conducted the oncological and obstetric results of 23 patients with early cervical cancer (stages IA2-IB3; International Federation of Gynecology and Obstetrics, 2018) who underwent RT in The Maternal and Child Health Care Hospital of Guiyang, China, from October 2004 to September 2018. RESULTS: 23 patients had cervical tumors of the squamous cell carcinoma histological type. All 23 patients retained reproductive function. The mean follow-up time was 112.87 ± 55.75 (36-199) months. The median tumor size was 2.00 ± 1.35 cm (imperceptible to the eyes 5.00 cm). No recurrence was observed in any of the patient cases. Among the patients with a tumor size > 4 cm (up to 5 cm), three patients who wished to preserve fertility accepted RT following neoadjuvant chemotherapy The pregnancy outcomes were as follows: 8 cases (47.06%) out of 17 cases who attempting pregnancy conceived 12 times.First-trimester abortion and the voluntary abandonment of pregnancy occurred in 4 cases (33.33%), respectively, one patient performed deliberate termination at 24 weeks of gestation. Second-trimester abortion occurred in three cases (25.0%) for chorioamnionitis. Premature delivery at 32 weeks occurred in one case (8.33%). CONCLUSION: Radical trachelectomy is a safe and effective treatment for women with early-stage cervical cancer preserving fertility biology. Patients with a cervical tumor sized > 4 cm can be pregnant after neoadjuvant chemotherapy and RT. Accordingly, this treatment is worthy of further exploration.

Proportion of Uterine Malignant Tumors in Patients with Laparoscopic Myomectomy: A National Multicenter Study in China.

BACKGROUND: The Food and Drug Administration recently announced that the use of morcellation may cause fibroids or pelvic dissemination and metastasis of uterine sarcoma; therefore, the use of morcellation is limited in the USA. A large sample study is necessary to assess the proportion of uterine malignant tumors found in patients with laparoscopic myomectomy. METHODS: A national multicenter study was performed in China. From 2002 to 2014, 33,723 cases were retrospectively selected. We calculated the prevalence and recorded the clinical characteristics of the patients with malignancy after morcellation application. A total of 62 cases were finally pathologically confirmed as malignant postoperatively. Additionally, the medical records of the 62 patients were analyzed in details. RESULTS: The proportion of postoperative malignancy after morcellation application was 0.18% (62/33,723) for patients who underwent laparoscopic myomectomy. Nearly 62.9% (39/62) of patients had demonstrated blood flow signals in the uterine fibroids before surgery. And, 23 (37.1%) patients showed rapid growth at the final preoperative ultrasound. With respect to the pathological types, 38 (61.3%) patients had detectable endometrial stromal sarcoma, 13 (21.0%) had detectable uterine leiomyosarcoma, only 3 (3.2%) had detectable carcinosarcoma, and 5 (8.1%) patients with leiomyoma had an undetermined malignant potential. CONCLUSIONS: The proportion of malignancy is low after using morcellation in patients who undergo laparoscopic myomectomy. Patients with fast-growing uterine fibroids and abnormal ultrasonic tumor blood flow should be considered for malignant potential, and morcellation should be avoided.

Reevaluation of the effect of lamivudine therapy preoperative to prevent HBV recurrence after liver transplantation.

BACKGROUND: Hepatitis B virus (HBV) recurrence may result in hepatic insufficiency or dysfunction of liver grafts. This study was to reevaluate the preventive effect of lamivudine therapy pretransplant on HBV recurrence after liver transplantation with combined lamivudine and hepatitis B immunoglobulin (HBIG) as a prophylactic regimen. METHODS: This is a single-center, retrospective study of 122 liver transplant recipients operated on from January 2002 to September 2006 at our hospital. All subjects showed positive hepatitis B surface antigen (HBsAg) and HBV DNA in blood, without HBV mutation in YMDD at the time of liver transplantation. The protocol with combined lamivudine and HBIG for preventing HBV recurrence was used on the day of operation. The initial immunosuppression therapy was identical. After one year follow-up, the recipients were divided into 2 groups: patients without HBV recurrence (group I) and patients with HBV recurrence (group II). Preoperative lamivudine therapy and postoperative mycophenolate mofetil (MMF) and glucocorticoid therapy were analyzed using the Wilcoxon's test and Stepwise logistic regression method. RESULTS: In the HBV recurrence group, the duration of pre-transplant lamivudine administration was significantly longer than that in the without HBV recurrence group (Z=-4.424, P=0.000). The HBV recurrence rate was significantly higher in patients with preoperative lamivudine therapy than in patients without lamivudine therapy (X2=13.11, P=0.000); the risk of HBV recurrence increased by a 10.909-fold in patients with pre-transplant lamivudine therapy compared with that in patients without lamivudine therapy (OR=10.909; 95% CI for OR: 2.86-41.67). Seven (63.6%) of 11 HBV recurrence recipients had YMDD mutants. The duration of MMF or glucocorticoid was not different between the 2 groups (Z(MMF)=-1.453, P(MMF)=0.146; Z(Pre)=-0.795, P(Pre)=0.427). No significant difference was noted in the HBV recurrent rate in patients with MMF duration < or =6 and >6 months (X2=0.185, P=0.667), as it was in patients with prednisone therapy < or =3 and >3 months (X2=0.067, P=0.793). CONCLUSIONS: With the protocol of combined lamivudine and HBIG for preventing HBV recurrence in liver transplantation recipients, liver transplantation candidates with positive HBV DNA should not be subjected to preoperative administration of lamivudine. A high dose of HBIG during the ahepatic period and in the early stage of post-transplantation can fulfill the treatment target as a long-term lamivudine therapy before liver transplantation. Long-term preoperative lamivudine treatment may result in an earlier HBV mutation in YMDD and increase the HBV recurrence rate and risk in the first year after transplantation.

Spectrum and risk factors for invasive candidiasis and non-Candida fungal infections after liver transplantation.

BACKGROUND: Invasive fungal infections are an important cause of posttransplant mortality in solid-organ recipients. The current trend is that the incidence of invasive candidiasis decreases significantly and invasive aspergillosis occurs later in the liver posttransplant recipients. The understanding of epidemiology and its evolving trends in the particular locality is beneficial to prophylactic and empiric treatment for transplant recipients. METHODS: A retrospective analysis was made of recorded data on the epidemiology, risk factors, and mortality of invasive fungal infections in 352 liver transplant recipients. RESULTS: Forty-two (11.9%) patients suffered from invasive fungal infection. Candida species infections (53.3%) were the most common, followed by Aspergillus species (40.0%). There were 21 patients with a superficial fungal infection. The median time to onset of first invasive fungal infection was 13 days, first invasive Candida infection 9 days, and first invasive Aspergillus infection 21 days. Fifteen deaths were related to invasive fungal infection, 10 to Aspergillus infection, and 5 to Candida infection. Invasive Candida species infections were associated with encephalopathy (P = 0.009) and postoperative bacterial infection (P = 0.0003) as demonstrated by multivariate analysis. Three independent risk factors of invasive Aspergillus infection were posttransplant laparotomy (P = 0.004), renal dysfunction (P = 0.005) and hemodialysis (P = 0.001). CONCLUSIONS: The leading etiologic species of invasive fungal infections are Candida and Aspergillus, which frequently occur in the first posttransplant month. Encephalopathy and postoperative bacterial infection predispose to invasive Candida infection. Posttransplant laparotomy and poor perioperative clinical status contribute to invasive Aspergillus infection. More studies are needed to determine the effect of prophylactic antifungal therapy in high risk patients.

[Effects of splenectomy on patients undergoing liver transplantation].

OBJECTIVE: To investigate the effects of splenectomy before or simultaneously in liver transplantation on the outcome of liver transplantation. METHODS: Splenectomy was performed on 29 of the consecutive 403 patients undergoing orthotopic liver transplantation (OLT) between February 1999 and May 2005, before the OTC in 23 of which and simultaneously during the OTC in 6 of which. Fifty-eight randomized selected age-matched patients undergoing OTC within the same period but without splenectomy were used as controls. The operation time, bleeding amount, transfusion amount, infection, acute rejection, survival rate, and post-operative recovery of platelet were compared between these groups. RESULTS: The average operation times of the pre-operatively splenectomized group (Group A) and intra-operatively splenectomized group (Group B) were 448.70 +/- 100.51 minutes and 526.67 +/- 99.93 minutes respectively, both significantly longer than that of the non-splenectomized group (Group C) (362.80 +/- 71.65 minutes, both P < 0.001). The intra-operative bleeding amount of the 2 splenectomized groups were both longer than that of the control group, however, not significantly. The intra-operative transfusion amounts of Group B was 3983 +/- 1885 ml, significantly more than that of Group C (2361 +/- 1246 ml, P < 0.05). The plasma transfusion amount of Group B was 8387 +/- 4231 ml, significantly more than that of Group C (4906 +/- 3108 ml, P < 0.05). The concentrated erythrocyte transfusion amount of Group A was 14.2 +/- 14.6 U, significantly more than that of Group C (5.1 +/- 6.6 U, P < 0.001). The bacterial infection rates of the Groups A and B were 91.3% and 100% respectively, both significantly higher than that of Group C (69.0%, both P < 0.05). The mycotic infection rates of the 2 splenectomized groups were 13% and 33.33% respectively, both significantly higher than that of Group C (29.3%), however, both not significantly. Acute rejection rate did not occurred in the 2 splenectomized groups, and in 4 cases of the non-splenectomized group, however, without significant differences among them. The post-operative bleeding rate of Group B was significantly higher than that of Group C (P < 0.05). The accumulative survival of Group C was significantly higher than that of Group B (P = 0.0001). The platelet counts 14 and 20 days after operation of the 2 splenectomized groups were all significantly higher than those of the non-splenectomized group (all P < 0.05), and were higher than the normal levels in some cases. CONCLUSION: Splenectomy does not benefit the patients undergoing liver transplantation whenever it is performed before or simultaneously in the liver transplantation.

[Dual, triple, and quadruple oral tacrolimus-based immunosuppression regimens after orthotopic liver transplantation: a randomised comparative study of regimens].

OBJECTIVE: To investigate the effects of tacrolimus-based immunosuppression regimens after orthotopic liver transplantation and search a reasonable regimen of combination therapy and suitable blood concentration of tacrolimus. METHODS: Ninety-four adult recipients of cadaveric livers were randomly divided into 3 groups to undergo different tacrolimus-based immunosuppression regimens: dual (tacrolimus + glucocorticoid), triple [tacrolimus + mycophenolate mofetil (MMF) + glucocorticoid]; quadruple [tacrolimus + MMF + glucocorticoid in addition of induction treatment by daclizumab]. The efficacy and safety of the 3 groups 6 months after the transplantation were compared. RESULTS: The frequencies of acute rejection were 25.9%, 11.1%, and 7.5% for the dual, triple, and quadruple therapy groups, that of the quadruple therapy group being significantly lower than that of the dual therapy group (P = 0.038). There were no significant differences in the rates Three months after transplantation, the levels of ALT and total cholesterol of the dual therapy groups were significantly higher than those of the quadruple therapy group (P(ALT) = 0.011, P(Tch) = 0.002). Within the first month post-operatively the concentration of tacrolimus of the triple therapy group could be controlled at the level 8 ng x ml(-1)-13 ng x ml(-1). CONCLUSIONS: Quadruple tacrolimus-based immunosuppression regimen is the most effective and safest, followed by the triple therapy and dual therapy. Low-dose tacrolimus combination therapy provides an effective protection to the liver graft with mild drug toxicity to the patient.

[The prevention and treatment of cytomegalovirus infection after liver transplantation].

OBJECTIVE: To review diagnosis and treatment experience of cytomegalovirus (CMV) infection after liver transplantation. METHODS: The clinical data of 96 patients receiving liver transplantation in our hospital from January 2001 to December 2002 were analyzed retrospectively. RESULTS: CMV infection occurred in 19 patients, blood IE-E antigen of CMV and PP65 antigen of CMV was detected in all the patients with CMV infection, 8 patients with CMV-IgM positivity, 3 of them presented with dyspnea, 4 with fever and 2 with jaundice, 14 patients had no symptoms of CMV infection. IE-E antigen of CMV and PP65 antigen of CMV in blood of 18 patients became negative after treatment with ganciclovir, 1 patients died from interstitial pneumonitis. CONCLUSIONS: Cytomegalovirus infection after liver transplantation is associated with many factors, the key point of CMV infection is prevention actively and early treatment after operation. The detection of blood antigen of CMV is necessary for early diagnosis and guiding treatment of CMV infection, ganciclovir is effective for treatment of CMV infection.

[Liver transplantation for hepatocellular carcinoma: prognostic analysis of 89 cases].

OBJECTIVE: To summarize the experience of liver transplantation (LT) for hepatocellular carcinoma (HCC) in one center and identify prognostic factors for survival. METHODS: The clinical data and survival results of 89 patients with HCC receiving LT from January 1999 to December 2003 were retrospectively analyzed and various clinicopathologic risk factors for actuarial survival and tumor free survival were evaluated by univariate and multivariate analysis. RESULTS: Six-month, 1-, and 2-year survival rates were 81.8%, 55.3% and 43.7%, respectively. The 6-month, 1-, and 2-year tumor free survival rates were 62.4%, 35.6% and 24.9%, respectively. The overall tumor recurrence and metastasis rate was 52.8%. In the univariate analysis, portal vein tumor thrombi (PVTT) (chi(2) = 15.14, P = 0.0001), tumor size (chi(2) = 15.05, P = 0.0001), hepatic cirrhosis background (chi(2) = 6.14, P = 0.0132), preoperative alpha-fetoprotein (AFP) level (chi(2) = 5.82, P = 0.0159) and histopathologic grading (chi(2) = 4.61, P = 0.0319) were found to be significantly associated with actuarial survival rate. Seven factors influencing tumor free survival included PVTT (chi(2) = 26.30, P < 0.0001), tumor size (chi(2) = 25.25, P < 0.0001), preoperative AFP level (chi(2) = 14.83, P = 0.0001), histopathologic grading (chi(2) = 12.54, P = 0.0004), tumor distribution (chi(2) = 12.73, P = 0.0004), number of nodules (chi(2) = 9.81, P = 0.0017) and cirrhosis background (chi(2) = 9.76, P = 0.0018). In the multivariate Cox regression analysis, the prognostic factors independently associated with patient survival were identified to be PVTT (RR = 4.721, P = 0.001), age (RR = 3.282, P = 0.007) and histopathologic grading (RR = 2.368, P = 0.037). For tumor free survival, histopathologic grading (RR = 3.739, P < 0.0001), PVTT (RR = 4.382, P = 0.001), cirrhosis background (RR = 0.421, P = 0.011), age (RR = 2.312, P = 0.027) and AFP (RR = 2.301, P = 0.047) were identified as prognostic parameters. CONCLUSIONS: LT is a good therapeutic option for strictly selected patients with HCC. PVTT and histopathologic grading are the most important factors of predicting outcomes of HCC patients undergoing LT. Further studies should be strengthened to establish a reliable and feasible selection criteria and an optimal prognosis scoring system for LT.

[Graft versus host disease after liver transplantation: a report of 3 cases].

OBJECTIVE: To document the clinical experience in the diagnosis and treatment of graft-versus-host disease(GVHD) after liver transplantation. METHODS: Clinical course was followed up and laboratory examinations were done in 3 patients with orthotopic liver transplantation (OLT) who developed acute GVHE. The diagnosis depended on clinical manifestations, skin biopsy, HLA typing and PCR short tandem repeat (PCR-STR). Immunosuppressive drugs were transferred and adjusted. RESULTS: Fever, shin rash, diarrhea and pancytopenia were found within 3 to 8 weeks after liver transplantation. The liver function was normal. CMV antigen (pp65) and EBV antibody (IgM) were negative. The donor's HLA was detected in the host's peripheral blood cells. One female recipient had the donor's Y chromosome microchimerism detected by PCR-STR. All 3 patients died from infection, alimentary tract bleeding, or multiple organ failure in the end. CONCLUSION: GVHD is not a rare complication easily misdiagnosed with pessimism out come after liver transplantation.

[Causes and management of respiratory complication after liver transplantation].

OBJECTIVE: To identify the causes of respiratory complications following liver transplantation (LT) and to discuss the management of these complications. METHODS: One hundred and twenty four cases with pulmonary complications in the first two weeks after LT were identified among 163 patients admitted to the First Affiliated Hospital, College of Medicine, Zhejiang University from February, 1999 to March, 2003. RESULTS: The incidence rate of complications was 76%(124/163) with the total cure rate of 92%(114/124). The cure rates of the various complications were as follows: pleural effusion 100%(113/113), pneumonia 92%(76/83), respiratory insufficiency 91%(59/65), pulmonary hypertension 98%(101/103), pulmonary edema 98(58/59), atelectasis 100%(4/4) and pneumothorax 100%(2/2). CONCLUSION: To drainage the pleural effusion with an unicameral venous catheter is safety and effective. To cure or prevent pneumonia and atelectasis, aseptic manipulating, aspiration of sputum and keeping respiratory channel open were the key measurements of treatment. Restrictive ventilatory functional disturbance (RVFD) and dysfunction of ventilation are two major types of respiratory insufficiency in early stage of post-transplantation. The causes of pulmonary hypertension and edema are associated with pulmonary angiotasis and blood flow volume, and the vasodilator and diuretic often introduced in the therapy.

Orthotopic liver transplantation in treatment of 77 patients with end-stage hepatic disease.

OBJECTIVE: To summarize the experience of human orthotopic liver transplantation (OLTx) in treatment of patients with end-stage hepatic disease and their perioperative management. METHODS: A retrospective analysis was made on OLTx performed in 77 patients from April 1993 to September 2001 in our department included combined liver-kidney transplantation (6 patients) and living related liver transplantation (2). Among them, 76 were adults and 1 was infant (67 males and 10 females). The donors included 75 non-heart beating donors and 2 living related donors. Veno-venous bypass was used only in 45 cases during the operation. immunosuppressive agents consisted of cyclosporine, cellcept, ALG corticosteroids and FK506. RESULTS: The one-year survival rates of grafts and recipients with benign hepatic disease were 75%. The recipients this year are surviving with good function of grafts. CONCLUSION: Liver transplantation is the best therapeutic method for a large number of patients with end-stage hepatic disease in China.

Functional changes of the heart and lung in perioperative period of orthotopic liver transplantation.

OBJECTIVE: To investigate the variation of functions of the heart and lung during orthotopic liver transplantation (OLT). METHODS: Pulmonary artery cannula and right radial artery cannula were indewelled before anaesthesia and the parameters of hemodynamics in different periods were monitored. Analysis of variance was used to reveal the variation among the groups. T hypothesis test in paired data was used to compare the preoperative parameters with those in each period during operation and after operation respectively, and to compare the parameters immediately after operation with those in each period after operation respectively. RESULTS: During the operation, heart rate increased, but blood pressure decreased significantly at the beginning of no-liver period, increased again in a short period and then increased progressively 12 h after operation. Pulmonary artery pressure (PAP) increased from before the no-liver period to 60 h after operation. Pulmonary wedge pressure changed in accordance with the variation of PAP. Cardiac output was maintained at a high-output level from before operation to 60 h after operation. Systemic vascular resistance (SVR) was within the normal limits before operation, whereas pulmonary vascular resistance (PVR) was lower than normal. In the no-liver period during the operation, SVR decreased significantly. Both SVR and PVR increased progressively and returned to normal postoperatively. CONCLUSIONS: The patients undergoing OLT have a high cardiac output and low resistance obstacle before and during the operation, and will recover gradually after operation. Monitoring hemodynamics during the peri-operative period is of significance in the prevention and treatment of pneumonedema and cardiac functional insufficiency.

Living related liver transplantation for an infant with biliary atresia.

OBJECTIVE: To sum up the preliminary experience in living related liver transplantation (LRLT). METHODS: A 9-month-old male infant with biliary atresia (BA) who had undergone an unsuccessful Kasai operation was defined as a candidate for LRLT. The donor was his 30-year-old mother. Her lateral lobe of the left liver was transplanted into the infant's body as the graft. The left branches of the portal vein, left hepatic artery and left hepatic vein of the graft were end-to-end anastomosed to the portal vein, hepatic artery proper and hepatic vein of the recipient respectively. Biliary drainage was reestablished via Roux-en-Y operation. RESULTS: The donor retained her liver function within 2 weeks after the operation. Steroid and FK506 were prescribed in immunosuppressive therapy for the recipient. The blood bilirubin level of the infant decreased to normal 2 weeks after operation. No acute rejection occurred. Biliary leakage in the early period after the transplantation was controlled by drainage, and E.coli infection was effectively treated with antibiotics. The donor and recipient are in satisfactory condition to the present. CONCLUSION: LRLT is advisable for children with biliary atresia.