False positive tardus-parvus waveforms after liver transplantation: a case of wide discrepancy between donor and recipient hepatic arteries mimicking anastomotic stenosis.

BACKGROUND: Parvus-tardus waveforms of the hepatic artery after liver transplantation usually indicate an arterial complication and severe impairment of hepatic arterial perfusion with a sensitivity of 91% and a specificity of 99.1%. Thus, it has been emphasized that detection of such waveforms should prompt emergency angiography. MATERIALS AND METHODS: Arterial reconstruction during a liver transplantation was successfully accomplished by an end-to-end anastomosis, performing a "flute-spout" widening of the anastomosis with a 7/0 prolene running suture between a small recipient proper hepatic artery and the donor common hepatic artery. RESULTS: On day 7 posttransplantation color Doppler ultrasonography revealed a parvus-tardus waveform pattern in the hepatic arterial flow. Computed tomographic (CT) angiography showed only a caliber discrepancy between the donor and recipient stumps, excluding an arterial stenosis or thrombosis. Since normal liver function persisted, the patient underwent routine follow-up. After 15 months the patient was alive and well; hepatic artery spectral waveforms were unchanged and liver functions were consistent with a mild hepatitis C virus (HCV) recurrence. CONCLUSIONS: This is a report of false positive tardus-parvus waveforms, due to a discrepancy between the donor and recipient arteries despite a wide anastomosis. Knowledge of technical reconstruction details may be helpful for correct interpretation of color Doppler findings. CT angiography should be considered before more invasive examinations.

Successful solitary pancreas transplantation with portal-enteric drainage following unsuccessful islet cell transplantation.

BACKGROUND: There are no data regarding the outcome of solitary pancreas transplantation (SPT) with portal venous drainage (PVD) following unsuccessful islet transplantation (ITx) after multiple islet injections into the portal vein. We herein describe the outcome of three SPTs with PVD performed after failed ITx. METHODS: Between October 2002 and December 2003, three SPTs with PVD were performed following unsuccessful ITx with multiple intraportal islet injections (mean 2.3 injections: range 2 to 3 injections) in two women and one man, aged 26, 49, and 60 years. Panel reactive antibody titer was 0% in all recipients. Immunosuppression was based on induction with either basiliximab (n = 2) or thymoglobulin (n = 1); maintenance therapy included steroids, mycophenolate mofetil, and tacrolimus. During the recipient operation, the absence of venous hypertension was established by direct measurement of portal pressure, before making the final decision to drain the pancreas into the portal vein. RESULTS: Portal pressures were 16 cm H2O, 14 cm H2O, and 13 cm H2O. Pancreas grafts were reperfused after a period of cold preservation of 638, 695, and 835 minutes, respectively. All grafts showed immediate endocrine function, maintaining their recipients insulin-independent for longest follow-ups of 8, 21, and 23 months, respectively. One recipient developed a nonocclusive venous thrombus that resolved with intravenous heparin infusion. CONCLUSIONS: Our experience showed that unsuccessful ITx with multiple intraportal injections does not necessarily preclude the possibility of subsequent successful SPT with PVD. Further experience is needed to define contraindications and possible complications of SPT with PVD following ITx.

Surveillance and rescue of pancreas grafts.

BACKGROUND: Technical failure rates are higher for pancreas allografts (PA) compared with other solid organs. Posttransplant surveillance and prompt availability of rescue teams with multidisciplinary expertise both contribute to improve this result. We herein report a single institution's experience with posttransplant surveillance and rescue of PA. METHODS: A retrospective survey was performed of a consecutive series of 177 whole organ pancreas transplants in 173 patients. Antithrombotic prophylaxis was used in all recipients and tailored on anticipated individual risk of thrombosis. During the first posttransplant week, all PA were monitored with daily Doppler ultrasonography. Surgical complications were defined as all adverse events requiring relaparotomy during the initial hospital stay or the first 3 posttransplant months. RESULTS: A total of 26 relaparotomies were performed in 25 patients (14.7%). One recipient needed two relaparotomies (0.6%). Graft rescue was attempted in patients without permanent parenchymal damage at repeat surgery and in 12 recipients diagnosed with nonocclusive vascular thrombosis. Overall 25 grafts (96.3%) were rescued and one was lost. One-year recipient and graft survivals in patients with versus without complications potentially leading to allograft loss were 92.6% and 63.0% versus 94.4% and 94.3%, respectively. Excluding complications for which graft rescue was not possible, 1-year graft survival rate increased to 78.7%. CONCLUSIONS: Close posttransplant surveillance can allow rescue of a relevant proportion of PA developing nonocclusive venous thrombosis or other surgical complications. Further improvement awaits better understanding of biological reasons for posttransplant complications jeopardizing PA survival and the development of more effective preventive measures.

Incidentally discovered adrenal masses: evaluation with gadolinium enhancement and fat-suppressed MR imaging at 0.5 T.

The purpose of the study is to evaluate the ability of Gd-enhancement and fat-suppressed MR imaging operating at midfield strength to characterize incidentally discovered adrenal masses. Sixty patients with 72 adrenal masses incidentally discovered during US or CT exams were studied with a 0.51 MR unit following clinical and laboratory evaluation. After Gd-DTPA intravenous administration a modified three-point Dixon technique was performed in all patients. This technique provided three images sets: conventional T1-weighted SE images, fat-suppressed T1-weighted images and water-suppressed T1-weighted images. Diagnosis was established by means of surgery (11 lesions), fine-needle biopsy (21 lesions) and stability on ultrasonographic follow-up for at least 1 year (range, 12-87 months) from adrenal lesion discovery (40 masses). In most of adenomas (n = 55) an homogeneous enhancement was observed on postcontrast T1WI; however, 15 out of these lesions showed a small focal spot of high intensity in Gd-enhanced fat-suppressed images. On the contrary, malignant conditions (n = 6) and pheochromocytoma (n = 1), all had inhomogeneous signal intensities which were relatively higher after Gadolinium injection as compared with the liver. The fat suppression technique demonstrated areas of bright signal intensity related to high vascularity. The performance of three observers in order to differentiate malignant from benign conditions showed sensitivity, specificity, diagnostic accuracy, positive and negative predictive values of 100, 88.5, 90, 50 and 100% on the basis of gadolinium enhancement only, by utilizing the Dixon technique. In conclusion, although Gd-enhancement and fat-suppressed sequence helped correctly differentiate among the groups of incidentally discovered adrenal masses, the degree of overlap suggests that it is still difficult to characterize individual patients. However, the modified three-point Dixon technique after contrast material administration appears to be a further capability of midfield MRI in the characterization of adrenal tissue.

Selection and preparation of candidates for combined liver-kidney transplantation: experience at a single center-two case reports.

BACKGROUND: The published experiences of combined liver-kidney transplantation (LKT) are favorable, but there is still no uniformity concerning the impact on hepatorenal syndrome, or in cases of symptomatic hepatorenal polycystic disease. Herein we describe our experience with two LKTs, with particular reference to the selection and preparation of the candidates, and the surgical approach. METHODS: Between 1996 and June 2003, we performed 430 liver transplants in 398 recipients, including two LKTs: one in a patient with hepatorenal polycystic disease (case 1) and the other in a patient with HBV(+) cirrhosis undergoing dialysis after a previous isolated kidney transplant (case 2). RESULTS: In case 1, LKT and right nephrectomy were performed 2 months after a left lumbar nephrectomy. In case 2, LKT was performed 10 months after an isolated kidney transplant, without removing the first graft, which recovered function after 3 months. Both patients are now in good health with functioning grafts. CONCLUSIONS: LKT requires careful selection and preparation of candidates to optimize the probability of success. In well-compensated dialyzed patients with cirrhosis due to viral hepatitis, we believe that a combined approach is indicated after antiviral therapy. In cases of hepatorenal cystic disease, a two-stage surgical approach makes it possible to eliminate the risk of infection and intracyst hemorrhage in nonfunctioning polycystic kidneys.

Interventional ultrasound: experience in 426 orthotopic liver transplantations.

BACKGROUND: The purpose of this study was to analyze the role of interventional ultrasound in the treatment of nonvascular complications in liver transplant recipients. METHODS: Between August 1996 and May 2003, we performed 426 OLTs in 394 patients, 287 men (73%) and 107 women (27%), mean age of 50 +/- 9.5 years (range 17 to 68.2). A total of 2556 diagnostic ultrasound examinations were performed, resulting in a mean of 5.9 per patient (range 2 to 21). The interventional maneuvers included: echo-guided biopsies; drainage of abdominal or thoracic effusions; drainage of abdominal, intrahepatic, or splenic collections; positioning of biliary drains; and use of the "rendezvous" technique. RESULTS: Six hundred seventy-seven echo-guided interventional maneuvers were performed in 394 OTL patients, comprising 417 (61.6%) biopsies and 260 (38.4%) therapeutic maneuvers. Eighty-one ascite drains were positioned (31.1%); in 73 cases, pleural effusions were drained (28.1%). Sixty-seven abdominal or intrahepatic collections were drained (25.8%), of which 36 (53.7%) were due to bilomas or biliary peritonitis, 15 (22.4%) hematomas, 4 (5.9%) hepatic abscesses, 11 (16.4%) infected abdominal collections, and 1 (1.5%) splenic abscess. Thirty-nine cases (15%) of biliary drainage were performed. In 33 cases (7.9%), the parenchymal biopsies were not diagnostic because of an inadequate specimen. The treatment success rate was 96.1%. No complications related to the therapeutic maneuvers were recorded, but there were 5 biopsy-related complications (1.2%). CONCLUSIONS: Echo-guided interventional maneuvers are safe, produce a high success rate, and represent an important option in the management of OLT patients.

Hepatic resection after liver transplantation as a graft-saving procedure: indication criteria, timing and outcome.

BACKGROUND: Hepatic resection is uncommon after liver transplantation (LT), but can be a graft-saving procedure in selected cases. Herein we describe the criteria, outcome, and timing of this procedure in our series. METHODS: Between January 1996 and December 2002, 397 LTs were performed in 367 recipients, of whom 12 patients (3.2%) subsequently underwent liver graft resections because of ischemic-type biliary lesions (ITBLs) (n = 5, 41.6%), segmental hepatic artery thrombosis (S-HAT)(n = 3, 25%), recurrent hepatocellular carcinoma (HCC) (n = 2, 16.6%), liver abscess (n = 1, 8.3%), or liver trauma (n = 1, 8.3%). The patients were divided into group 1 (n = 3 all with S-HAT) who underwent early resections (within 3 months of LT), and group 2 (n = 9) who underwent late resections (after 3 months). The outcomes and postoperative mortality ratio (within 30 days) were compared. RESULTS: The resections consisted of four left lobectomies, three right hepatectomies, two extended right hepatectomies, one segmentectomy, one anterior trisegmentectomy, and one right lateral sectoriectomy. The perioperative mortality rate was 66.6% in group 1 (one case of myocardial infarction and one of sepsis), and 22% in group 2 (one case of sepsis and one of hepatic failure). CONCLUSIONS: Late resections in stable patients with damage confined to the graft yield good prognosis. Even major resections are feasible graft-saving procedures. In contrast, early hepatic resections in S-HAT are associated with a worse outcome. Retransplantation should be considered the first-choice option. Sepsis significantly affects the postsurgical course.

An alternative and simple method to consistently prepare viable isolated human islets for clinical transplantation.

We describe a method to consistently prepare human islets for transplantation. By combining a simple collagenase digestion method and a density gradient purification system, we were able to obtain successful isolations (>/=200,000 islet equivalents, >/=50% purity) in 69% of processed glands. No reagent of animal source was used. Isolated islets were morphologically well maintained and functionally competent, with sterility confirmed in 97% of cases. Two patients were transplanted with islets prepared by this method; graft function was demonstrated for a few months. Improved simplicity and consistency, together with adequate quality of the preparations, are the main features of this isolation method.

Percutaneous cholecystostomy for acute cholecystitis in critically ill patients.

BACKGROUND/AIMS: The aim of this study was to ascertain the therapeutic efficacy of percutaneous cholecystostomy in a selected group of high-risk patients who were physiologically unable to tolerate an open procedure. METHODOLOGY: We reviewed the hospital records of 11 critically ill patients who underwent percutaneous cholecystostomy for acute cholecystitis during the intensive care unit course of major underlying diseases. RESULTS: Percutaneous cholecystostomy was easily performed in all cases (feasibility rate: 100%). No procedure-related death was recorded and minor complications occurred in 2 patients (18%). Percutaneous cholecystostomy led to resolution of the sepsis in all but 1 patient with gangrenous calcolous cholecystitis who required emergent cholecystectomy (success rate: 91%). Percutaneous cholecystostomy was the permanent treatment in all patients with acalcolous cholecystitis. Among patients with calcolous cholecystitis, 4 underwent delayed elective cholecystectomy, 1 required no further treatment, and 2 eventually died from the evolution of their underlying diseases. After a mean follow-up of 25 months (range: 12-32 months), none of the patients managed non-operatively required surgery or re-hospitalization. CONCLUSIONS: Ease of performance, low complication rate, and high success rate make percutaneous cholecystostomy the procedure of choice for critically ill patients with acute cholecystitis. Whenever possible, percutaneous cholecystostomy should be followed by elective cholecystectomy. However, especially in acalcolous cholecystitis, it may constitute the definitive treatment.

Cytology in the percutaneous treatment of hydatid cysts. A report of four cases.

Four cases of percutaneous treatment of hydatid cysts are reported. Cytologic examination of the cyst fluid is important to confirm the diagnosis in patients who did not develop antibodies. Gomori stain gives the best results in identifying the three elements of a hydatid cyst: scolices, hooklets and laminated membranes. Moreover, staining for viability assessment gives information about the success of drug treatment.

Transrectal ultrasonography and cervical neoplasia. A preliminary report.

Transrectal ultrasonography is a new diagnostic method recently introduced in the study of normal and pathologic pelvis. The Authors describe their preliminary experience with the use of a rectal linear probe in the evaluation of the carcinoma of the cervix. This ultrasonographic method has resulted very useful in providing an imaging of cervical cancer in evaluating its effective diffusion and in precising demeasurements of the neoplastic mass. The results are particularly encouraging and justify continued experimentation.

Surgical complications after liver transplantation.

AIM: The number of liver transplantations in Italy has steadily increased over the last 10 years as a result of the use of donors aged more than 60 years. The use of organs with a reduced functional reserve has been compensated for by improvements in immunosuppressive therapy, surgical techniques and the management of postoperative complications. This article describes the incidence and treatment of the main surgical complications after liver transplantation. METHODS: Between January 1996 and June 2003, 398 patients received 430 transplants at our Centre. Thirty-seven early relaparotomies were performed (8.6%), including 12 retransplantation (2.8%). The 1-, 3- and 5-year actuarial survival of the patients was 79.8%, 72.2% and 67.5%, and that of the grafts was 75.9%, 68% and 63.4%. Perioperative mortality was 10.5% (with no intraoperative deaths). RESULTS: The overall incidence of biliary complications was 31.6%, 9.1% of which were due to the removal of the Kehr tube. There were 42 (9.8%) anastomotic stenoses, 5 (1.2%) extra-anastomotic stenoses, 1 (0.2%) anastomotic leak, 5 (1.2%) extra-anastomotic leaks, and 19 (4.4%) ischemic-type biliary lesions. The overall incidence of vascular complications was 6.9%: 7 (1.6%) cases of hepatic artery thrombosis, 17 (4.0%) arterial stenoses, 1 (0.2%) arterial pseudoaneurysm, 4 (0.9%) cases of portal thromboses and 1 (0.2%) case of caval laminar thrombosis. Eight patients (1.9%) developed massive and persistent post-transplant ascites and/or hydrothorax. CONCLUSION: The use of donors aged more than 60 years makes it possible to maintain high standards of patient and graft survival that is not only due to the optimisation of immunosuppressive protocols, but also to improvements in surgical techniques, intensive care and the management of surgical complications.

[Adrenal myelolipomas: their magnetic resonance assessment]. / Mielolipomi del surrene: valutazione con risonanza magnetica.

Adrenal myelolipomas are rare nonfunctioning neoplasias consisting of a variable mixture of mature fat and bone marrow tissue. In the present study MRI appearances of six adrenal myelolipomas are presented. MR exams of six patients in which a conclusive diagnosis of adrenal myelolipomas was reached by means of surgery (1 case), US-guided fine-needle biopsy (3 cases) and typical diagnostic imaging in association with stability on US follow-up for at least two years (2 cases) were retrospectively evaluated. MR sequences protocol included pre- and post-contrast (Gd-DTPA) SE T1-weighted images and SE proton density and T2-weighted images. Five adrenal masses were examined by means of combination of gadolinium administration with a SE T1-weighted modified three-point Dixon technique. Three different MR structural patterns were pointed out: a) homogeneous hyperintense masses on T1-weighted images with intermediate signal on T2-weighted images, suggestive for predominantly fat-containing lesions (2 cases); b) heterogeneous masses with fat intensity areas and hyperintense areas on T2-weighted images and on post-contrast T1-weighted images, suitable for mixed fatty and myeloid elements (2 cases); c) nodules hypointense to the liver on T1-weighted images and hyperintense on T2-weighted images and after gadolinium administration, suggesting tumors primarily composed of myeloid cells (2 cases). A precise determination of fatty and myeloid elements within the lesions was observed by means of "water" and "fat" images provided by modified three-point Dixon technique. In conclusion, MRI allows to determine the various structural components of myelolipomas and therefore appears to be a very reliable technique in the diagnosis and characterization of the different structural patterns of this rare adrenal pathology.

[Review of a case series of cervical cysts and evaluation of the efficacy of sclerotherapy with tetracycline hydrochloride in thyroid cystic lesions]. / Revisione di una casistica di cisti della regione cervicale e valutazione dell'efficacia del trattamento sclerosante con tetraciclina cloridrato nelle lesioni cistiche tiroidee.

We have reexamined a series of 1119 patients consecutively submitted to fine needle aspiration of nodules of the neck. Among these in 166 cases ultrasonography combined with aspiration suggested the presence of cysts. 60 patients were submitted to cyst aspiration and 34 were aspirated and submitted to cyst injection with tetracycline hydrochloride. The patients were followed up clinically and ultrasonically 3 and 12 months after treatment. Cure was defined as the absence of any residual cystic lesion and an ultrasonic cyst volume less than 50% with respect to basal after 12 months from the start of treatment. 18 of the 60 (30%) patients only aspirated and 24 of the 34 patients (70%) in the tetracycline group were cured (statistically significant; p < 0.005). We conclude that tetracycline seems an effective sclerotherapy in treatment of thyroid cysts.

The use of ACTH and beta-endorphin levels to measure the stress impact and safety of extracorporeal lithotripsy.

The authors measured the plasma levels of beta-endorphin and adrenocorticotropic hormone (ACTH) related to pain in 11 urologic patients who underwent extracorporeal lithotripsy. The study included eight male and three female patients (aged 24 to 65 years) with single kidney stones of less than 20 mm who were treated with the Lithoring Multi-One device. The device delivered 2,000 shock waves from 18 kV to 25 kV, increasing by 1 kV every 250 shock waves. Three patients experienced pain, but only one required intravenous analgesia. The assay of plasmatic ACTH and beta-endorphin is proposed to control the safety and the stress impact of new devices and techniques. In addition, the study demonstrates the medicolegal relevance of such an assay in the evaluation of pain.