The appearance of donor heparin in the recipient after reperfusion of a liver graft.

The release of heparin has been mentioned as one of the causes of hypocoagulability after reperfusion of the liver graft. It has been ascribed to endogenous heparin released from the donor liver or to exogenous heparin in the preservation fluid that is released into the recipient after sequestration into the graft during preservation. The aim of this study was to investigate whether systemic administration of heparin to the donor before the hepatectomy contributes to the appearance of heparin in the recipient after reperfusion. We studied 20 patients undergoing an auxiliary heterotopic liver transplantation; 15 donors had received heparin immediately before circulation arrest (median 300 IU/kg body weight), but 5 had not. The thrombin time (TT), activated partial thromboplastin time (aPTT), and heparin neutralization test were determined at several intervals during the transplantation.

[Favorable results of auxiliary heterotopic liver transplantation in patients with end-stage chronic liver insufficiency]. / Gunstige resultaten van auxiliaire heterotope levertransplantatie bij patiënten in het eindstadium van chronische leverinsufficiëntie.

Auxiliary heterotopic liver transplantation (HLT), which avoids removal of the host liver, may improve the results of liver transplantation in patients with end-stage chronic liver disease. However, the results of HLT have so far been disappointing. In 1986 a program of HLT was started in the University Hospital Rotterdam-Dijkzigt. Eighteen patients with chronic liver failure underwent HLT. Twelve out of 18 (67%) patients were discharged 25 days after transplantation with normal liver function. Six patients died within 3 months after operation due to septic causes. Three months after transplantation ascites was no longer detectable and oesophageal varices had disappeared in all surviving recipients of HLT. The actuarial 3 and 12 months survival rate was 67%. Hepatitis B virus reinfection was seen in all patients. In two patients cirrhosis of the graft developed within one year. These data suggest that HLT in patients with chronic liver failure gives long-term metabolic support and adequate decompression of portal system, and is associated with a morbidity and mortality comparable to that of orthotopic liver transplantation.

[Partial hepatectomy for benign or malignant liver diseases; experience in 94 patients]. / Partiële hepatectomie wegens benigne of maligne leveraandoeningen; ervaring bij 94 patiënten.

In this retrospective study, we analyse the results of 94 partial liver resections performed between 1972 and January 1989. The resections were performed for malignant (48 patients) and benign (46 patients) liver tumours. Nine patients (9.6%) died of resection-related complications. Mortality was significantly lower in the patients with resections for benign liver tumours (2.2%) compared with patients with resections for malignant liver tumours (16.7%) (p less than 0.05). In the patients who survived the first 30 days, complications occurred in 25.9%. The 5-year survival of patients with a primary malignant liver tumour (57%) is significantly (p = 0.05) better than in patients with a secondary malignant liver tumour (19%). From this study we conclude that partial liver resections for primary or secondary liver tumours can be performed with an acceptable mortality and morbidity, and should be the therapy of choice for selected patients.

[Boerhaave's syndrome: also in the emergency room]. / Het Boerhaave-syndroom: ook op de eersteharthulp.

Two men, aged 52 and 57 years, had vomited and then developed chest pain, dyspnoea and tachypnoea. After a myocardial infarction had been excluded in the cardiac emergency room, further examination revealed a rupture of the oesophagus. This was treated surgically with the ultimate creation of a tubular stomach. Both patients then recovered well. The Boerhaave's syndrome, a 'spontaneous' perforation of the oesophagus, is a rare and potentially lethal condition which should be diagnosed at an early stage. Pain in the chest, dyspnoea and vomiting are frequent symptoms. A cardiac cause is sometimes erroneously suspected. Subcutaneous emphysema is a major indication for a perforation of the oesophagus. The chest X-ray shows also mediastinal emphysema and infiltrative abnormalities; in case of doubt a second X-ray should be made some hours later.

[Liver transplantation in acute liver insufficiency: definitive replacement or auxiliary liver?]. / Levertransplantatie bij acute leverinsufficiëntie: definitieve vervanging of hulplever?

Orthotopic liver transplantation (OLT) has greatly improved the chances of survival in patients with acute hepatic failure. However, this mode of treatment requires lifelong immunosuppressive medication and negates the potential recovery of the host liver. In theory, auxiliary heterotopic liver transplantation (HLT) offers the diseased host liver a chance to regenerate, so that immunosuppression can be tapered off and eventually stopped. In the University Hospital Rotterdam Dijkzigt OLT and HLT were performed in two patients, with acute and subacute hepatic failure respectively. The patient undergoing OLT recovered quickly but needed a successful re-OLT after a serious rejection episode. The removed diseased liver showed no signs of regeneration at histology. The patient undergoing HLT also recovered well. HIDA scanning as well as liver biopsies of the host liver and the grafted liver 1 and 6 months after transplantation indicated full recovery of the host liver, so that immunosuppression is being tapered off.

[Cystic dilatation of the choledochus. 9 cases]. / Dilatation kystique du cholédoque. Neuf observations.

A retrospective study of 9 cases of extra-hepatic biliary cyst is presented. Prior to admission to our hospital, 5 patients had been operated upon elsewhere. This initial operation proved to be of great importance. In 4 patients initial excision of the cyst was performed resulting in complete regression of symptoms, and no further surgery was required. In 5 patients the cyst was not excised initially and cysto-enterostomy was performed. Recurrence of symptoms and complaints, with major morbidity, occurred in all but one of these patients. After several operations, only final excision of the cyst definitively suppressed the symptoms, but in one patient the cyst could no longer be excised. Cysto-enterostomy results in recurrent symptoms and cholangitis and should be avoided. Early excision of extra-hepatic biliary cysts should be performed whenever technically feasible, not only to prevent these complications but also because of the risk of malignant degeneration related to the cyst.

[Possibilities and limitations of heterotopic auxiliary liver transplantation]. / Möglichkeiten und Grenzen der heterotopen auxiliären Lebertransplantation.

Although auxiliary heterotopic liver transplantation offers theoretical advantages over orthotopic liver replacement, clinical results have heretofore been dismal. After development of a technique of reduced size liver grafts provided with portal and arterial blood and venous drainage via the suprahepatic V. cava (HLT) in experimental animals, this method was applied in 21 transplantations in 19 patients. 11 of 16 patients with chronic liver insufficiency and one of three patients with fulminant liver failure survived transplantation for at least 1 year. HLT was well tolerated even by high-risk patients. Possibilities and limitations of this novel approach are discussed.

Resection of liver metastases in patients with breast cancer: survival and prognostic factors.

AIMS: Patients with breast cancer metastasized to the liver have a median survival of 4-33 months and treatment options are usually restricted to palliative systemic therapy. The aim of this observational study was to evaluate the effectiveness and safety of resection of liver metastases from breast cancer and to identify prognostic factors for overall survival. METHODS: Patients were identified using the national registry of histo- and cytopathology in the Netherlands (PALGA). Included were all patients who underwent resection of liver metastases from breast cancer in 11 hospitals in The Netherlands of the last 20 years. Study data were retrospectively collected from patient files. RESULTS: A total of 32 female patients were identified. Intraoperative and postoperative complications occurred in 3 and 11 patients, respectively. There was no postoperative mortality. After a median follow up period of 26 months (range, 0-188), 5-year and median overall survival after partial liver resection was 37% and 55 months, respectively. The 5-year disease-free survival was 19% with a median time to recurrence of 11 months. Solitary metastases were the only independent significant prognostic factor at multivariate analysis. CONCLUSION: Resection of liver metastases from breast cancer is safe and might provide a survival benefit in a selected group of patients. Especially in patients with solitary liver metastasis, the option of surgery in the multimodality management of patients with disseminated breast cancer should be considered.

Repair of giant midline abdominal wall hernias: "components separation technique" versus prosthetic repair : interim analysis of a randomized controlled trial.

BACKGROUND: Reconstruction of giant midline abdominal wall hernias is difficult, and no data are available to decide which technique should be used. It was the aim of this study to compare the "components separation technique" (CST) versus prosthetic repair with e-PTFE patch (PR). METHOD: Patients with giant midline abdominal wall hernias were randomized for CST or PR. Patients underwent operation following standard procedures. Postoperative morbidity was scored on a standard form, and patients were followed for 36 months after operation for recurrent hernia. RESULTS: Between November 1999 and June 2001, 39 patients were randomized for the study, 19 for CST and 18 for PR. Two patients were excluded perioperatively because of gross contamination of the operative field. No differences were found between the groups at baseline with respect to demographic details, co-morbidity, and size of the defect. There was no in-hospital mortality. Wound complications were found in 10 of 19 patients after CST and 13 of 18 patients after PR. Seroma was found more frequently after PR. In 7 of 18 patients after PR, the prosthesis had to be removed as a consequence of early or late infection. Reherniation occurred in 10 patients after CST and in 4 patients after PR. CONCLUSIONS: Repair of abdominal wall hernias with the component separation technique compares favorably with prosthetic repair. Although the reherniation rate after CST is relatively high, the consequences of wound healing disturbances in the presence of e-PTFE patch are far-reaching, often resulting in loss of the prosthesis.

Barrett's ulcer: cause of spontaneous oesophageal perforation.

We report two patients, who presented within six months with the classic clinical picture of 'spontaneous' oesophageal perforation, which was caused by a perforated Barrett's ulcer. These two cases underline the importance of postoperative endoscopy in ruling out intrinsic oesophageal disease as the cause of the rupture in every patient, who survives this life threatening condition.