RESUMEN
BACKGROUND: Bile duct injury is a serious complication following liver resection. Few studies have differentiated between leakage from small peripheral bile ducts and central bile duct injury (CBDI), defined as an injury leading to leakage or stenosis of the common bile duct, common hepatic duct, right or left hepatic duct. This study analysed the incidence, risk factors and consequences of CBDI in liver resection. METHODS: Patients undergoing liver resection between 1990 and 2007 were included in this study. Those having resection for bile duct-related pathology or trauma, or after liver transplantation were excluded. Characteristics and outcome variables were collected prospectively and analysed retrospectively. RESULTS: There were 19 instances of CBDI in 462 liver resections (4·1 per cent). One-third of patients with CBDI required surgical reintervention and construction of a hepaticojejunostomy. Resection type (P < 0·001), previous liver resection (P = 0·039) and intraoperative blood loss (P = 0·002) were associated with an increased risk of CBDI. Of all resection types, extended left hemihepatectomy was associated with the highest incidence of CBDI (2 of 9 procedures). CONCLUSION: Patients undergoing extended left hemihepatectomy or repeat hepatectomy were at increased risk of CBDI.
Asunto(s)
Conducto Colédoco/lesiones , Hepatectomía/efectos adversos , Hepatopatías/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Drenaje , Femenino , Humanos , Lactante , Complicaciones Intraoperatorias/etiología , Complicaciones Intraoperatorias/cirugía , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Cuidados Preoperatorios/métodos , Pronóstico , Estudios Prospectivos , Reoperación , Estudios Retrospectivos , Factores de Riesgo , Adulto JovenRESUMEN
Heme oxygenase-1 (HO-1) has been suggested as a cytoprotective gene during liver transplantation. Inducibility of HO-1 is modulated by a (GT)(n) polymorphism and a single nucleotide polymorphism (SNP) A(-413)T in the promoter. Both a short (GT)(n) allele and the A-allele have been associated with increased HO-1 promoter activity. In 308 liver transplantations, we assessed donor HO-1 genotype and correlated this with outcome variables. For (GT)(n) genotype, livers were divided into two classes: short alleles (<25 repeats; class S) and long alleles (> or =25 repeats; class L). In a subset, hepatic messenger ribonucleic acid (mRNA) expression was correlated with genotypes. Graft survival at 1 year was significantly better for A-allele genotype compared to TT-genotype (84% vs. 63%, p = 0.004). Graft loss due to primary dysfunction (PDF) occurred more frequently in TT-genotype compared to A-receivers (p = 0.03). Recipients of a liver with TT-genotype had significantly higher serum transaminases after transplantation and hepatic HO-1 mRNA levels were significantly lower compared to the A-allele livers (p = 0.03). No differences were found for any outcome variable between class S and LL-variant of the (GT)(n) polymorphism. Haplotype analysis confirmed dominance of the A(-413)T SNP over the (GT)(n) polymorphism. In conclusion, HO-1 genotype is associated with outcome after liver transplantation. These findings suggest that HO-1 mediates graft survival after liver transplantation.
Asunto(s)
Supervivencia de Injerto/fisiología , Hemo-Oxigenasa 1/genética , Trasplante de Hígado/fisiología , Polimorfismo de Nucleótido Simple , Donantes de Tejidos , Adulto , Biopsia , Femenino , Genotipo , Humanos , Hígado/enzimología , Pruebas de Función Hepática , Trasplante de Hígado/inmunología , Trasplante de Hígado/patología , Masculino , Persona de Mediana Edad , Polimorfismo Genético , ARN Mensajero/genéticaRESUMEN
--Cholangiocarcinoma is a rare malignancy originating from the biliary epithelium. The disease can arise anywhere in the biliary tract: intrahepatic, perihilar or distal. The overall prognosis for cholangiocarcinoma is poor. --The treatment necessitates a multidisciplinary approach. --Radical resection of the extrahepatic bile ducts, usually in combination with concomitant partial liver resection, remains the only curative treatment. --Liver transplantation in combination with neoadjuvant chemoradiation therapy seems to be promising in a highly selected group of patients. --Palliative treatment should be targeted at adequate biliary drainage, preferably by stenting. --Radiotherapy and systemic chemotherapy are not standard treatment and should be applied in an experimental setting only. --New options such as photodynamic therapy and tyrosine kinase inhibitors are promising, but still experimental treatments.
Asunto(s)
Neoplasias de los Conductos Biliares/diagnóstico , Conductos Biliares Intrahepáticos , Procedimientos Quirúrgicos del Sistema Biliar/métodos , Colangiocarcinoma/diagnóstico , Trasplante de Hígado , Neoplasias de los Conductos Biliares/cirugía , Neoplasias de los Conductos Biliares/terapia , Colangiocarcinoma/cirugía , Colangiocarcinoma/terapia , Terapia Combinada , Humanos , Cuidados Paliativos , Pronóstico , Resultado del TratamientoRESUMEN
Liver transplantation has been an accepted treatment for end-stage liver disease since the 1980s. Currently it is a highly successful treatment for this indication. The aim of this review is to give a general update on recent developments in the field of liver transplantation. In the last decades considerable progress has been made in the care of liver transplant candidates and recipients. At present the one- and five-year patient survival rates are approximately 85 and 75%. The indications for liver transplantation are shifting and the number of absolute contraindications is decreasing. In the coming years, an increase in the number of transplant candidates can be expected. An important problem is the shortage of donor organs, for which many solutions are being explored. A recently introduced method for recipient selection is the MELD score using simple laboratory measurements. Perioperative care at the present time is characterised by a high degree of standardisation and rapidly declining blood loss during transplantation. Long-term care includes awareness and management of recurrent disease. Important causes of morbidity and mortality such as de novo malignancies and cardiovascular disease should be adequately screened for and managed. With the increasing success of liver transplantation, physicians should aim at reaching a normal life expectancy and quality of life for transplant recipients.
Asunto(s)
Hepatopatías/cirugía , Trasplante de Hígado/tendencias , Humanos , Terapia de Inmunosupresión , Trasplante de Hígado/métodos , Pronóstico , Calidad de Vida , Donantes de Tejidos , TrasplanteRESUMEN
INTRODUCTION: Hepatic stellate cell (HSC) activation is a key event in wound healing as well as in fibrosis development in the liver. Previously we developed a technique to induce HSC activation in slices from rat liver. Although this model provides a physiologic, multicellular milieu that is not present in current in vitro models it might still be of limited predictive value for the human situation due to species-differences. Therefore, we now aimed to evaluate the applicability of human liver slices for the study of HSC activation. METHOD: Liver slices (8 mm diameter, 250 microm thickness) were generated from human liver tissue and incubated for 3 or 16 h with 0-15 microl of carbon tetrachloride (CCl4) after which ATP-content and expression levels of HSC (activation) markers was determined. RESULTS: Human liver slices remained viable during incubation as shown by constant ATP levels. Incubation with CCl(4) caused a dose-dependent decrease in viability and an increase in mRNA expression of the early HSC activation markers HSP47 and alphaB-crystallin, but not the late markers for HSC activation, alphaSMA and pro-collagen 1a1. Synaptophysin mRNA expression remained constant during incubation with or without CCl4, indicating a constant number of HSC in the liver slices. CONCLUSION: We developed a technique to induce early toxicity-induced HSC activation in human liver slices. This in vitro model provides a multicellular, physiologic milieu to study mechanisms underlying toxicity-induced HSC activation in human liver tissue.
Asunto(s)
Hepatocitos/citología , Hepatocitos/efectos de los fármacos , Hígado/efectos de los fármacos , Modelos Biológicos , Tetracloruro de Carbono/toxicidad , Supervivencia Celular/efectos de los fármacos , Proteínas del Choque Térmico HSP47/genética , Hepatocitos/metabolismo , Hepatocitos/patología , Humanos , Técnicas In Vitro , Hígado/citología , Hígado/metabolismo , Hígado/patología , ARN Mensajero/genética , ARN Mensajero/metabolismo , Cadena B de alfa-Cristalina/genéticaRESUMEN
UNLABELLED: OBJECTIVE. To describe the experience with combined liver and kidney transplantation at the University Medical Centre Groningen, The Netherlands. DESIGN. Retrospective. METHOD: Data were analysed from all patients who underwent combined liver and kidney transplantation in the University Medical Centre Groningen, in the period November 1994-December 2005. RESULTS: During the study period 582 orthotopic liver transplantations and 1026 isolated kidney transplantations were performed. 16 patients underwent combined liver and kidney transplantation: 4 were children (aged 17 months-16 years) and 12 were adults (aged 19-59 years). For all patients, both organs were obtained from the same post-mortem donor. Indications for combined liver and kidney transplantation were primary hyperoxaluria type I (n=6), polycystic liver and kidney disease (n=3) and unrelated liver and kidney failure (n=7). The 1- and 5-year survival rate was 88% (14/16), which was not significantly different from the results after isolated liver transplantation. Two patients died 11 days and 74 months after combined transplantation, due to complications from unsuccessful retransplantation of the liver for hepatic artery thrombosis and secondary biliary cirrhosis, respectively. A third patient died 51 days after combined transplantation due to sepsis. CONCLUSION: Combined liver and kidney transplantation was a life-saving intervention in this selected group of patients with combined liver and kidney failure. Patient survival was comparable to that of patients undergoing isolated liver transplantation.
Asunto(s)
Fallo Renal Crónico/cirugía , Trasplante de Riñón , Fallo Hepático/cirugía , Trasplante de Hígado , Adolescente , Adulto , Niño , Preescolar , Femenino , Supervivencia de Injerto , Humanos , Hiperoxaluria Primaria/complicaciones , Lactante , Trasplante de Riñón/métodos , Trasplante de Riñón/mortalidad , Trasplante de Hígado/métodos , Trasplante de Hígado/mortalidad , Masculino , Persona de Mediana Edad , Países Bajos/epidemiología , Complicaciones Posoperatorias/mortalidad , Estudios Retrospectivos , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
BACKGROUND: Seemingly conflicting results have been reported on the prevalence and severity of inflammatory bowel disease after liver transplantation. Regimens with different combinations of drugs can be used for immunosuppression after transplantation. AIM: To study retrospectively the prevalence of inflammatory bowel disease after liver transplantation, and the possible relationship with maintenance immunosuppressive regimens. METHODS: All 78 patients with end-stage primary sclerosing cholangitis (48 patients) or autoimmune cirrhosis (30 patients), transplanted between 1979 and July 2001, and with a follow-up of at least 1 year, were eligible for this study. In addition to patient and transplant characteristics, data on inflammatory bowel disease and immunosuppression before and after transplantation were collected. The Kaplan-Meier method was used for survival analysis. Possible risk factors for inflammatory bowel disease after transplantation were analysed by Cox univariate and multivariate regression. RESULTS: The median follow-up after transplantation was 7.2 years (range, 1.1-22.3 years). Nine of 25 patients with pre-transplant inflammatory bowel disease experienced flare-ups after transplantation. Six of 53 patients without pre-transplant inflammatory bowel disease developed de novo inflammatory bowel disease after transplantation. The cumulative risks (standard errors in parentheses) for inflammatory bowel disease were 6% (3%), 12% (4%) and 20% (5%) at 1, 3 and 5 years after transplantation, respectively. The inflammatory bowel disease-free survival was significantly higher in patients not receiving tacrolimus vs. those receiving tacrolimus, in patients receiving azathioprine vs. those not receiving azathioprine and in patients taking the regimen prednisolone-azathioprine-ciclosporin A vs. those taking tacrolimus-prednisolone. Pre-transplant inflammatory bowel disease and the use of tacrolimus were found to be independent predictors for inflammatory bowel disease after transplantation. CONCLUSIONS: The prevalence of inflammatory bowel disease after liver transplantation is affected by the immunosuppression used. Azathioprine seems to have a protective effect and tacrolimus a promoting effect.
Asunto(s)
Inmunosupresores/efectos adversos , Enfermedades Inflamatorias del Intestino , Trasplante de Hígado , Complicaciones Posoperatorias/etiología , Adolescente , Adulto , Anciano , Azatioprina/uso terapéutico , Ciclosporina/uso terapéutico , Quimioterapia Combinada , Femenino , Estudios de Seguimiento , Humanos , Enfermedades Inflamatorias del Intestino/inducido químicamente , Enfermedades Inflamatorias del Intestino/prevención & control , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/prevención & control , Estudios Prospectivos , Factores de Riesgo , Tacrolimus/efectos adversosRESUMEN
We report the molecular epidemiology of Enterococcus faecalis in liver transplant patients transplanted at the University Hospital Groningen (The Netherlands) as determined by amplified fragment length polymorphism (AFLP) typing. A total of 133 E. faecalis isolates were cultured from the faeces and throat (95 isolates) or clinical sites (35 isolates) of 43 liver transplant patients. Among these 133 isolates, 15 different AFLP types could be identified with 90% AFLP similarity. Of these 15 groups, nine contained isolates from more than one patient, which may indicate transmission of E. faecalis isolates between patients. In five of these groups transmission could be explained by the fact that patients carrying identical strains were staying in the same ward at the same time. One of these epidemic isolates (AFLP type K) distinguished itself by colonizing 23 liver transplant patients during 15 months. Antimicrobial susceptibility testing did not reveal any multi-resistant isolates. This study showed that transmission of susceptible E. faecalis isolates occurs frequently on the liver transplant wards. Detection of this transmission and understanding of the mechanism is important, as it might also be an indicator of possible transmission of enterococci resistant to antibiotics.
Asunto(s)
Enterococcus faecalis , Trasplante de Hígado , Adulto , Enterococcus faecalis/clasificación , Enterococcus faecalis/efectos de los fármacos , Enterococcus faecalis/aislamiento & purificación , Hospitales Universitarios , Humanos , Pruebas de Sensibilidad Microbiana , Epidemiología Molecular , Países Bajos/epidemiologíaRESUMEN
Besides the conventional laboratory tests, thromboelastography (TEG) is used to monitor hemostasis during liver transplantation. A previous pilot study suggested a beneficial effect of recombinant activated factor VII (rFVIIa) on transfusion requirements in liver transplantation. In the present study, we assess the effects of rFVIIa on coagulation variables and TEG. In six study patients, the prothrombin time (PT), the activated partial thromboplastin time (aPTT) and TEG variables [reaction time (r), kinetic time (k), or clot formation time, alpha angle (alpha), and maximal amplitude (MA)] were recorded before and after the administration of a bolus of 80 microg/kg rFVIIa. These patients were compared with six controls who did not receive rFVIIa. In contrast with the control group, a significant shortening of PT (P = 0.028) and aPTT (P = 0.028), r (P = 0.046) and k (P = 0.043) values, and a significant incline of the alpha angle (P = 0.028) were noticed after injection of rFVIIa, whereas MA increased not significantly (P = 0.075). rFVIIa rapidly improved coagulation variables in liver transplant patients including PT and aPTT. Of the TEG variables, r, k and alpha angle significantly improved, and MA showed a trend to increase. These data suggest that rFVIIa not only influences the speed of clot formation, but also the physical properties of the clot, which cannot be detected by routine coagulation tests.
Asunto(s)
Coagulación Sanguínea/efectos de los fármacos , Factor VII/farmacología , Trasplante de Hígado , Proteínas Recombinantes/farmacología , Tromboelastografía , Adulto , Pruebas de Coagulación Sanguínea , Estudios de Casos y Controles , Factor VII/administración & dosificación , Factor VIIa , Humanos , Fallo Hepático/sangre , Proteínas Recombinantes/administración & dosificaciónRESUMEN
Hepatic artery thrombosis is a major cause of graft failure in liver transplantation. Use of donor interponates are common, but results are controversial because of necrosis or thrombosis after rejection. Reperfusion injury, hypoxia and free radical production determinate the survival. The aim of the study was to create an 'ideal' arterial interponate. Autologous, tubular graft lined with mesothelial cells, prepared from the posterior rectus fascia sheath, was used for iliac artery replacement in eight mongrel dogs for six months under immunosuppression. Patency rate was followed by Doppler ultrasound. Eight grafts remained patent and another two are patent after one year. The patency rate was good (median Doppler flow: 370 cm/sec) and there was no necrosis, thrombosis or aneurysmatic formation. The grafts showed viable morphology with neoangiogenesis, appearance of elastin, smooth muscle and endothelial cells. Electron microscopy showed intact mitochondrial structures without signs of hypoxia. Tissue oxygenation was good in all cases with normal (< 30 ng/ml) myeloperoxidase production. In conclusion, this autologous graft presents good long-term patency rate. Viability, arterialisation and low thrombogenicity are prognostic factors indicating usability of the graft in the clinical practice without the risk of rejection. Further investigations such as cell cultures and standardisation are necessary.
Asunto(s)
Arteria Ilíaca/trasplante , Trasplante de Hígado , Grado de Desobstrucción Vascular , Animales , Perros , Terapia de InmunosupresiónRESUMEN
Recently the first three liver transplantations from living donors were performed in The Netherlands. The motivations to proceed with this new procedure were threefold; the existing shortage of post-mortem organ donors, the successful transplants reported in the literature and the supposedly better organ quality and favourable-logistics of the procedure. This new procedure is in line with a recent advisory report on organ donation from the National Health Council of The Netherlands. As long as there is a shortage of post-mortem donors, living donation is a necessary treatment for patients with otherwise fatal liver insufficiency. However this should not keep public and governmental organisations from its continuing efforts to promote post-mortem donation. These should also include a discussion regarding changes to the organ donation law.
Asunto(s)
Trasplante de Hígado/métodos , Donadores Vivos , Humanos , Trasplante de Hígado/legislación & jurisprudencia , Donadores Vivos/legislación & jurisprudencia , Países Bajos , Obtención de Tejidos y Órganos , Resultado del Tratamiento , Listas de EsperaRESUMEN
In patients with colorectal liver metastases, resection is the only intentionally curative therapy. It is stated that follow-up after a resection of primary colorectal malignancies does not favourably influence patient outcome. However, follow-up can identify 12% of patients with isolated liver metastases in whom liver resection should be performed. One third of these patients can be cured by liver surgery. In general, medical care is provided for lower chances of survival and freedom of disease. Local ablative therapies are probably useful, but need to be evaluated in a randomised trial. Tumour progression of hepatocellular carcinomas in patients, during the long waiting time for liver transplantation, necessitates the use of radiofrequency ablation. Minimally invasive techniques for liver resections seem to be promising but need to be evaluated before they can be more widely applied.
Asunto(s)
Neoplasias Colorrectales/cirugía , Neoplasias Hepáticas/secundario , Neoplasias Hepáticas/cirugía , Neoplasias Colorrectales/mortalidad , Neoplasias Colorrectales/patología , Estudios de Seguimiento , Humanos , Neoplasias Hepáticas/mortalidad , Atención Perioperativa , Factores de Riesgo , Análisis de SupervivenciaRESUMEN
BACKGROUND: Pulmonary embolism (PE) and intracardiac thrombosis (ICT) are rare but potentially lethal complications during orthotopic liver transplantation (OLT). METHODS: We aimed to review clinical and pathological correlates of PE and ICT in patients undergoing OLT. A systematic review of the literature was conducted using MEDLINE and ISI Web of Science. RESULTS: Seventy-four cases of intraoperative PE and/or ICT were identified; PE alone in 32 patients (43%) and a combination of PE and ICT in 42 patients (57%). Most frequent clinical symptoms included systemic hypotension and concomitant rising pulmonary artery pressure, often leading to complete circulatory collapse. PE and ICT occurred in every stage of the operation and were reported equally in patients with or without the use of venovenous bypass or antifibrinolytics. A large variety of putative risk factors have been suggested in the literature, including the use of pulmonary artery catheters or certain blood products. Nineteen patients underwent urgent thrombectomy or thrombolysis. Overall mortality was 68% (50/74) and 41 patients (82%) died intraoperatively. CONCLUSION: Mortality was significantly higher in patients with an isolated PE, compared to patients with a combination of PE and ICT (91% and 50%, respectively; P < 0.001). Intraoperative PE and ICT during OLT appear to have multiple etiologies and may occur unexpectedly at any time during the procedure.
Asunto(s)
Cardiopatías/epidemiología , Complicaciones Intraoperatorias/epidemiología , Trasplante de Hígado , Embolia Pulmonar/epidemiología , Trombosis/epidemiología , Adolescente , Adulto , Niño , Preescolar , Terapia Combinada , Femenino , Cardiopatías/diagnóstico , Cardiopatías/etiología , Cardiopatías/terapia , Mortalidad Hospitalaria , Humanos , Hipertensión Pulmonar/epidemiología , Hipertensión Pulmonar/etiología , Hipotensión/epidemiología , Hipotensión/etiología , Lactante , Recién Nacido , Complicaciones Intraoperatorias/diagnóstico , Complicaciones Intraoperatorias/etiología , Complicaciones Intraoperatorias/terapia , Masculino , Persona de Mediana Edad , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/etiología , Embolia Pulmonar/terapia , Factores de Riesgo , Choque/epidemiología , Choque/etiología , Choque/terapia , Tromboelastografía/estadística & datos numéricos , Trombosis/diagnóstico , Trombosis/etiología , Trombosis/terapiaRESUMEN
Although several randomized controlled trials (RCTs) have shown the efficacy of antifibrinolytic drugs in liver transplantation, their use remains debated due to concern for thromboembolic complications. None of the reported RCTs has shown a higher incidence of these complications in treated patients; however, none of the individual studies has been large enough to elucidate this issue completely. We therefore performed a systematic review and meta-analysis of efficacy and safety endpoints in all published controlled clinical trials on the use of antifibrinolytic drugs in liver transplantation. Studies were included if antifibrinolytic drugs (epsilon-aminocaproic acid, tranexamic acid (TA) or aprotinin) were compared with each other or with controls/placebo. Intraoperative red blood cell and fresh frozen plasma requirements, the perioperative incidence of hepatic artery thrombosis, venous thromboembolic events and mortality were analyzed. We identified 23 studies with a total of 1407 patients which met the inclusion criteria. Aprotinin and TA both reduced transfusion requirements compared with controls. No increased risk for hepatic artery thrombosis, venous thromboembolic events or perioperative mortality was observed for any of the investigated drugs. This systematic review and meta-analysis does not provide evidence for an increased risk of thromboembolic events associated with antifibrinolytic drugs in liver transplantation.
Asunto(s)
Antifibrinolíticos/uso terapéutico , Trasplante de Hígado/efectos adversos , Adulto , Anciano , Ácido Aminocaproico/uso terapéutico , Aprotinina/uso terapéutico , Transfusión Sanguínea/estadística & datos numéricos , Ensayos Clínicos Controlados como Asunto/estadística & datos numéricos , Femenino , Arteria Hepática , Humanos , Trasplante de Hígado/métodos , Trasplante de Hígado/mortalidad , Masculino , Persona de Mediana Edad , Tasa de Supervivencia , Tromboembolia/tratamiento farmacológico , Tromboembolia/etiología , Trombosis/tratamiento farmacológico , Trombosis/etiología , Ácido Tranexámico/uso terapéutico , Resultado del Tratamiento , Trombosis de la Vena/tratamiento farmacológico , Trombosis de la Vena/etiologíaRESUMEN
Renal dysfunction is frequently seen after orthotopic liver transplantation (OLT). Aprotinin is an antifibrinolytic drug which reduces blood loss during OLT. Recent studies in cardiac surgery suggested a higher risk of postoperative renal complications when aprotinin is used. The impact of aprotinin on renal function after OLT, however, is unknown. In 1,043 adults undergoing OLT, we compared postoperative renal function in patients who received aprotinin (n = 653) or not (n = 390). Using propensity score stratification (C-index 0.82) and multivariate regression analysis, aprotinin was identified as a risk factor for severe renal dysfunction within the first week, defined as increase in serum creatinine by >or= 100% (OR = 1.97, 95% CI = 1.14-3.39; p = 0.02). No differences in renal function were noted at 30 and 365 days postoperatively. Moreover, no significant differences were found in the need for renal replacement therapy (OR = 1.52, 95% CI = 0.94-2.46; p = 0.11) or in 1-year patient survival rate (OR = 1.14, 95% CI = 0.73-1.77; p = 0.64) in patients who received aprotinin or not. In conclusion, aprotinin is associated with a higher risk of transient renal dysfunction in the first week after OLT, but not with a higher need for postoperative renal replacement therapy or an increased risk of mortality.
Asunto(s)
Aprotinina/uso terapéutico , Hemostáticos/uso terapéutico , Pruebas de Función Renal , Riñón/fisiología , Trasplante de Hígado/fisiología , Adulto , Aprotinina/efectos adversos , Creatinina/sangre , Femenino , Fibrinólisis/efectos de los fármacos , Hemostáticos/efectos adversos , Humanos , Riñón/efectos de los fármacos , Hepatopatías/clasificación , Hepatopatías/cirugía , Trasplante de Hígado/mortalidad , Masculino , Persona de Mediana Edad , Análisis Multivariante , Complicaciones Posoperatorias/inducido químicamente , Análisis de Regresión , Terapia de Reemplazo Renal , Estudios Retrospectivos , Factores de Riesgo , Análisis de SupervivenciaRESUMEN
The finer branches of the biliary tree (FBBT) contain a regenerative compartment. We hypothesized that preservation of the FBBT together with its microvasculature will lead to recovery of biliary damage and prolonged preservation of bile ductules during the development of chronic liver allograft rejection. The interlobular bile ducts, portal bile ductules and extraportal biliary cells with and without microvessels were studied in sequential biopsies in five patients who fulfilled the Banff criteria of early chronic rejection (CR) (imminence group). Biopsies of CR patients (n = 12) served as controls. Biopsies were double immunostained with CD34 (microvessels) and cytokeratin 7 (biliary structures). Proliferation and proangiogenic activity were assessed with Ki67 and VEGF-A immunostaining. Severe damage of bile ducts in the imminence group did not progress to significant bile duct loss. This was associated with a high proliferative activity in all biliary structures and preservation of the microvascular compartment. VEGF-A expression was increased in all but the reperfusion biopsies. In conclusion, both regenerative activity of the FBBT and an intact microvascular compartment are associated with less damage of the biliary tree and could therefore be prerequisites for biliary regeneration.
Asunto(s)
Conductos Biliares Extrahepáticos/patología , Conductos Biliares Intrahepáticos/patología , Trasplante de Hígado/patología , Adolescente , Adulto , Conductos Biliares Extrahepáticos/fisiopatología , Conductos Biliares Intrahepáticos/fisiopatología , División Celular , Niño , Preescolar , Humanos , Recién Nacido , Pruebas de Función Hepática , Trasplante de Hígado/fisiología , Preservación de Órganos , RegeneraciónRESUMEN
Liver transplantation is the treatment of choice in selected patients with end-stage liver disease. Postoperative complications often require surgical re-intervention. This study is a retrospective single-centre study to assess the incidence and type of surgical re-intervention during the in-hospital period after liver transplantation and to identify predictors of this re-intervention. From 1994 to 2002, 231 consecutive adult liver transplantations were performed. Re-intervention was classified as biliary, vascular, bleeding, septicaemia, re-transplantation or as miscellaneous. One hundred and thirty-nine surgical re-interventions were performed in 79 of 231 patients (34%). Septicaemia (44%) and bleeding (27%) were the most frequent indications for re-intervention, followed by biliary (10%) re-intervention. Vascular re-intervention, re-transplantation, and re-intervention for miscellaneous reasons, were performed in 7% each. Of all analysed variables (gender, age, diagnosis, acute liver failure, Child-Pugh classification, Karnofsky score, previous abdominal surgery, creatinine clearance, prothrombin time, anti-thrombin, platelet count, surgical technique, cold ischaemia time, warm ischaemia time, functional anhepatic time, anatomic anhepatic time, revascularisation time, year of transplantation, aprotinin administration, transfused platelet concentrate, and red blood cell transfusion requirements), only the number of transfused red blood cell concentrates (RBCs) was identified as a predictor of surgical re-intervention. Median RBC transfusion requirement during liver transplantation was 2.9 l (range 0-18.8 l) in the re-intervention group compared with 1.5 l (range 0-13.4 l) in the non-re-intervention group (P<0.001). This study revealed intraoperative blood loss as the main determinant of early surgical re-intervention after liver transplantation and emphasises the need for further attempts to control blood loss during liver transplantation.
Asunto(s)
Pérdida de Sangre Quirúrgica , Transfusión de Eritrocitos , Trasplante de Hígado , Adulto , Anciano , Femenino , Mortalidad Hospitalaria , Humanos , Trasplante de Hígado/efectos adversos , Trasplante de Hígado/mortalidad , Masculino , Persona de Mediana Edad , Reoperación , Estudios RetrospectivosRESUMEN
The search for an unknown primary tumour is often time-consuming, costly and unrewarding. Positron emission tomography might be an effective method for screening the body for malignant deposits. We present the case of a woman with a symptomatic liver tumour of unknown origin. Several investigations did not reveal a primary tumour, but PET scanning showed a hot spot in the pelvis, suggesting either a primary tumour or a metastatic deposit. During operation, a primary Fallopian tube carcinoma was detected. Histopathological examination of the resected liver tumour revealed a metastasis of the Fallopian tube carcinoma. This case report demonstrates that PET scanning can be useful in the diagnostic process in patients with unknown primary tumour, and that a symptomatic liver tumour can be the first sign of Fallopian tube carcinoma.
Asunto(s)
Adenocarcinoma/diagnóstico por imagen , Adenocarcinoma/secundario , Neoplasias de las Trompas Uterinas/diagnóstico por imagen , Neoplasias Hepáticas/secundario , Neoplasias Primarias Desconocidas/diagnóstico por imagen , Tomografía Computarizada de Emisión , Femenino , Humanos , Neoplasias Hepáticas/diagnóstico por imagen , Persona de Mediana EdadRESUMEN
UNLABELLED: Post-transplant lymphoproliferative disease (PTLD) is one of the major causes of morbidity and mortality in transplantation patients. A primary Epstein-Barr virus (EBV) infection is a major risk factor for developing PTLD. The aim of this study was to determine circulating EBV DNA after liver transplantation in pediatric patients in relation to primary EBV infection and development of PTLD. EBV serology was performed before transplantation. Every 4 weeks after transplantation a competitive quantitative polymerase chain reaction (PCR) assay for EBV nuclear antigen-1 was performed in 13 patients. Patients were followed for development of a PTLD. Before transplantation four patients were EBV seropositive and nine patients were EBV seronegative. In one of the four patients who were EBV seropositive before transplantation, EBV DNA became detectable after transplantation, with a peak load of 3600 copies/mL. None of these four patients developed a PTLD. Eight of the nine patients who were EBV seronegative before transplantation developed positive EBV DNA samples. EBV DNA was first detected at a mean of 64 days after transplantation (range 38-89). The mean peak EBV DNA load was 79,700 copies/mL (3600-446,000). Two of these patients developed PTLD, but they could not be identified based on prior or concomitant EBV PCR results. CONCLUSIONS: In pediatric liver transplantation EBV DNA load is higher in patients with a primary infection than in patients who were EBV seropositive before transplantation. The EBV PCR cannot be used to identify individual patients who develop PTLD. However, elevated EBV DNA load can be used to detect a group of patients at increased risk for PTLD.
Asunto(s)
ADN Viral/sangre , Herpesvirus Humano 4/aislamiento & purificación , Trasplante de Hígado/efectos adversos , Trastornos Linfoproliferativos , Carga Viral , Adolescente , Niño , Preescolar , Infecciones por Virus de Epstein-Barr/diagnóstico , Infecciones por Virus de Epstein-Barr/virología , Humanos , Lactante , Trastornos Linfoproliferativos/diagnóstico , Trastornos Linfoproliferativos/prevención & control , Trastornos Linfoproliferativos/virología , Reacción en Cadena de la Polimerasa , Estudios ProspectivosRESUMEN
BACKGROUND: Growth factors play a role in wound healing and tumour growth. The aim of this study was to compare the effect of partial hepatectomy (PH) and laparotomy on serum levels of growth factors and acute-phase proteins in patients with colorectal liver metastases and to correlate these levels with prognosis after PH. METHODS: Epidermal growth factor (EGF), hepatocyte growth factor (HGF), insulin like growth factor-I (IGF-I), insulin, interleukin-6 (IL-6), C-reactive protein (CRP) and serum amyloid-A (SAA) were determined in portal and systemic serum in 24 PH patients and 9 laparotomy patients. RESULTS: No differences were found in the clinicopathological characteristics of PH and laparotomy patients with the exception of the number of metastases, blood loss and operation time. The response of SAA, CRP and IGF-I was lower in PH patients than in laparotomy patients (P < 0.02). PH was associated with a higher IL-6 (P = 0.02) and HGF (P = 0.055) response than laparotomy. A higher HGF and CRP response was associated with a poorer prognosis. Total IGF-I was negatively correlated with the resected liver volume (r = -0.48, P < 0.05). CONCLUSIONS: PH is associated with a lower acute-phase and total IGF-I response and a higher HGF and IL-6 response compared with laparotomy. HGF and CRP responses had an influence on the prognosis.