Liver transplantation in malignant primary hepatic neoplasms.

Between April 1986 and August 1990, 151 liver transplantations were performed at our institution, 16 (11%) of them in 14 patients with primary hepatic tumors. There were 12 hepatocellular carcinomas, 1 angiosarcoma, and 1 Klatskin tumor. None of the tumors was resectable, and there was no preoperative evidence of extrahepatic tumoral extension. Exploratory laparotomy was performed prior to transplantation in three patients and selective embolization of the tumor in six patients. There was no difference in the intraoperative requirements for blood or plasma in the patients with hepatic tumors when compared with other transplant recipients (28.6 +/- 23.6 units packed red blood cells [PRBC] versus 20.1 +/- 17.8 units PRBC, and 17.9 +/- 12.2 units plasma versus 17.1 +/- 10.5 units plasma, respectively). Extracorporeal venovenous bypass was used in all but one patient. There was no significant differences in the incidence of acute rejection or in the length of hospitalization in these patients when compared with other transplant recipients. All patients received triple immunosuppressive therapy (corticosteroids, azathioprine, and cyclosporin A). Intraoperative mortality was zero. At a mean of 13.3 months' follow-up (range: 1 to 47 months), 2 of 14 patients had died of sepsis and 1 of terminal cirrhosis (autopsies revealed no evidence of tumor recurrence); 3 patients (21%) had recurrences of the tumor (1 in the central nervous system and liver, and the other 2 in the lung). One of the three patients with a recurrent tumor is still alive after 16 months. The remaining nine patients (64%) are still alive.

[Manometric changes induced by antireflux surgery (Nissen) and its relation to pH measurement and clinical findings. An analysis 6 months after the intervention]. / Modificaciones manométricas inducidas por la cirugía antirreflujo (Nissen) y su relación con los hallazgos pH-métricos y clínicos. Análisis a los 6 meses de la intervención.

We analyzed the preoperative ambulatory 24 hour ph-metric and manometric characteristics in a group of 20 patients treated surgically for gastroesophageal reflux (PGER) by Nissen fundoplication. At 6 months post-surgery they were reevaluated instrumentally (manometric and 24 hour ph-metry) and clinically. All ph-metric parameters of PGER (total reflux time, clearance, number of episodes, number of episodes greater than 5 minutes duration and duration of longest episode) were significantly improved (p less than 0.01-0.05) post-operatively (as globally as by position supine and upright) and this improvement was associated with resolution of symptoms in 19 (95%) patients. Of the manometric parameters evaluated (lower esophageal sphincter pressure--LESP--and length--LESL, peristaltic, triphasic, biphasic, absent and simultaneous waves and relaxation of LES) surgery only produced improvement in the lower esophageal sphincter pressure (LESP) and length (LESL) (p less than 0.001). We conclude that antireflux surgery (Nissen) by improving the pressure and length of the LES is capable of producing clinical and ph-metric remission in almost all (95%) of patients studied six months after.

Recipient factors as determinants of mortality after adult liver transplantation.

The factors that can influence the outcome of orthotopic liver transplantation (OLT) are numerous. The purpose of this study was to determine the effects of recipient preoperative factors on patient mortality. Between April 1986 and April 1998 a total of 600 OLTs were performed in our institution. We retrospectively reviewed our first 203 consecutive primary adult OLTs with at least 4 years of follow-up. A case-control comparison was performed between survivors and nonsurvivors, and differences in recipient variables were studied for their correlation with patient mortality. A logistic regression analysis was also performed. Mortality was significantly increased among those with fulminant hepatic failure (FHF) (66.6%, p = 0.003), primary cancer (63.1%, p = 0.018), females (46.1%, p = 0. 043), encephalopathy grade IV (72.7%, p = 0.012), recipients under respiratory support (69.2%, p = 0.031), and ABO-incompatible transplants (80%, p = 0.05). FHF, primary cancer, and female gender were the only variables that had a significant association with mortality in the logistic regression analysis. A higher incidence of prolonged respiratory support, bacterial and fungal infections, pneumonia, and chronic rejection contributed to the lower outcome observed in females. These results stress the need for continuous evaluation of the selection criteria of candidates for OLT suffering from primary cancer and FHF. The impact of recipient gender on mortality warrants further analysis but suggests that in the future more attention must be paid to the influence of this factor on the final outcome of OLT.

Orthotopic liver transplantation in primary liver tumors.

Among 283 orthotopic liver transplantations made during the last 6 years at our institution, 22 (7.77%) were done on 19 patients with unresectable hepatic malignant tumors [hepatocellular carcinoma (17), angiosarcoma (1), and cholangiocarcinoma (1)]. None of them showed extrahepatic invasion, and only one had lymph node involvement. Cyclosporin A, corticosteroids, and azathioprine were administered for 3 months after the procedure, and maintenance therapy involved the first two drugs. Acute rejection rate and hospital stay were not significantly different compared with non-tumoral grafted patients. Three patients were retransplanted, one with uncontrolled acute rejection and two with chronic rejection. Intraoperative mortality was zero. Eight patients (42.1%) were alive at a mean follow-up of 31 months (range, 6-74). Four 22.2%) died with tumor recurrence, three of sepsis, two of respiratory insufficiency, one of hepatitis recurrence with cirrhosis, and one of primary lung neoplasia. If adequately selected, primary liver tumor patients may benefit from liver transplantation. Future research with adjuvant therapies will improve the results.