The role of transplantation in small hepatocellular carcinoma complicating cirrhosis of the liver.

Of 176 hepatic transplants performed from 1986 to December 1992, 27 patients had small hepatocellular carcinoma (< or = 5 centimeters) complicating cirrhosis of the liver. All patients were asymptomatic for the hepatic malignancy and the diagnosis was established in each instance preoperatively by means of serial sonographic scans and alpha-fetoprotein levels. Cirrhosis was classified as Child's A in eight instances, as Child's B in 16 and Child C's in three. The cause was alcoholic in three patients, posthepatitic in 21 patients (eight hepatitis B virus [HBV] positive and 13 hepatitis C virus [HCV] positive) and undetermined in three. The in-hospital mortality rate was 11 percent (three of 27). Additionally, five patients died at different intervals after transplantation: only two died of neoplastic recurrence at 12 and 32 months, respectively (7.4 percent rate). Actuarial survival rates were 82 percent at one year and 71 percent at three years, with a mean follow-up period of 32 months (range six to 78 months). Morbidity related to the procedure was a relevant problem: 21 percent of the patients had prompt resumption of normal life while 37 percent required repeated hospitalization and 42 percent required strict control on an outpatient basis. The most frequent problem was HBV or HCV reinfection of the grafted liver, which occurred in 42 percent. Based on this experience, transplantation of the liver has shown an excellent oncologic accuracy for small hepatocellular carcinoma in cirrhosis of the liver, thus representing the most rational surgical procedure for patients with Child's B and Child's C cirrhosis classification. The relevant mortality and morbidity rates, strictly related to this procedure, suggest other options as more appropriate in those with Child A cirrhosis at this time.

[Carotid stenosis with contralateral occlusion. Surgical indications and results]. / Stenosi carotidea con occlusione controlaterale. Indicazioni chirurgiche e risultati.

Recent American and European trials have clearly defined that surgery provides best treatment for unilateral critical stenosis of internal carotid artery. Isolated reports seem to confirm this trend also in cases with carotid critical stenosis with controlateral occlusion, even if a major surgical risk may be expected. In our experience in the last two years, out of 96 carotid enderterectomies 20 presented a controlateral occlusion. After routine pre-operative assessment, with particular regard to DSA "cross-filling" study, intervention has been performed under general anesthesia with BP+EEG cerebral monitoring in both groups of patients. In the non occluded group temporary shunt has been used in 19.7% of cases, in occluded the incident of shunting was 40%. Operative morbidity and mortality in the second group was surprisingly absent, with cumulative 4.1% complication rate. Our experience confirms that risks and results in carotid endoarterectomy are similar in both groups of patients.

Liver transplantation for small HCC in cirrhosis.

Segmental liver resection is generally considered the treatment of choice for small HCC in cirrhotic livers. Although in selected patients with small encapsulated nodules and low alpha-fetoprotein levels long-term survival can be expected after resection, Western experience is still limited, and follow-up studies too short so that the data presently available cannot be considered satisfactory. The true value of alcoholization as a possible alternative therapy in these patients is still to be ascertained. When using these treatment modalities, the major problem is the high tumour recurrence within the liver. Three main reasons could explain these clinical observations: 1. inadequate resection of the original tumor; 2. unrecognized multifocal HCC; 3. newly generated tumours in the remnant cirrhotic parenchyma. The rationale for liver transplantation is the oncological accuracy of the ablation of the liver, and the possibility of a simultaneous cure of the associated cirrhosis. In our programme of liver transplantation, begun in 1985, we accepted as an indication small HCC in cirrhotic livers. We present here our initial experience with 19 cases.

Dysarthria and cerebellar ataxia: late occurrence of severe neurotoxicity in a liver transplant recipient.

Neurological complications of cyclosporin (CyA) therapy are frequent, usually occurring within the 1st month after transplantation. Though leukoencephalopathy is one of them, it is rarely documented. Here we report the case of an anti-HCV-positive patient with cirrhosis who underwent liver transplantation and developed cyclosporin-induced leukoencephalopathy. The presenting symptoms were dysarthria, difficulty walking, and dysphagia. They were first noted 6 months after transplantation in association with an episode of recurrent HCV acute hepatitis. White matter abnormalities were evident on computed tomography (CT) scanning and magnetic resonance (MR) imaging. This condition improved to some degree after cyclosporin withdrawal. To our knowledge this is the second reported case of CyA neurotoxicity occurring late after liver transplantation. Moreover, the association with acute hepatitis suggests the possibility of graft dysfunction as a contributing and triggering factor.

Biliary complications in orthotopic liver transplantation: experience with a modified technique of duct-to-duct reconstruction.

Biliary complications are described as frequent causes of morbidity during the postoperative course of orthotopic liver transplantation (OLTx), even in recent papers. The authors report here on their experience with duct-to-duct anastomosis as their method of choice for biliary reconstruction in a consecutive series of 100 OLTx in adult patients. The original technique, as described by Starzl, was modified by the authors by performing a wide, longitudinal plasty of both the donor and recipient bile ducts, joined together with two polidioxanone running sutures, producing the effect of a side-to-side anastomosis. This technique was used in all procedures, even when a significant discrepancy was evident between the ducts (n = 10). Follow-up was completed in 100% of the patients for a period of 2-40 months (mean 13.1 months). Four major complications (4%) occurred including hepatic abscesses due to ascending cholangitis, T-tube dislocation, partial occlusion by a branch of the T-tube at the anastomotic site, and disruption of the bile duct after T-tube removal. In four other patients, transient abdominal pain followed removal of the stent. Neither strictures nor fistulas were observed. Choledochocholedochostomy on a T-tube stent represents, in our experience, the technique of choice for biliary reconstruction in OLTx. The procedure, as described in the present study, proved to be safe in preventing strictures and leakages and appears to be feasible in nearly 100% of all adult patients undergoing OLTx.