Infant pediatric liver transplantation results equal those for older pediatric patients.

METHODS: From July 1984 to July 1995, 99 pediatric patients underwent 127 orthotopic liver transplants (OLT) at the University of Wisconsin Children's Hospital. The patients were divided into four groups according to age at time of transplant: group I, 0 to 6 months (n = 20); group II, 6 to 12 months (n = 18); group III, 1 to 2 years (n = 10); and group IV, 2 to 18 years (n = 51). A retrospective analysis was performed to compare these four groups with regard to preoperative indications and demographics, intraoperative technique, complications, and survival. All patients were followed up for 2 to 13 years. RESULTS: Biliary atresia was the most common indication for OLT in all four groups. The average waiting period varied from 19+/-18 days for group I to 44+/-64 days for group IV. Reduced-size liver transplant (I, 41%; II, 52%; III, 28%; IV, 21%), split-liver transplant (I, 0%; II, 7.4%; III, 17%; IV, 2.9%), or whole-liver transplant techniques were used. Although postoperative Intensive Care Unit stay was longer for the 0- to 6-month-old patients (I, 20+/-64; II, 7.6+/-9; III, 13+/-17; IV, 6.8+/-14 days), the total hospital stay (I, 43+/-63; II, 33+/-34; III, 32+/-20; IV, 29+/-31 days) was similar for all patients. The incidence of hepatic artery thrombosis (I, 19%; II, 19%; III, 27%; IV, 16%), biliary tract complications (I, 4.8%; II, 15%; III, 20%; IV, 14%), and retransplantation (I, 9.5%; II, 41%; III, 33%; IV, 14%) were not significantly different between the four groups. Portal vein thrombosis (I, 9.5%; II, 11%; III, 6.6; IV, 0%) and primary nonfunction (I, 9.5%; II, 7.4%; III, 0%; IV, 3.1%) occurred more frequently in the 0- to 6-month and 6- to 12-month groups, however, the 1-, 5-, and 10-year survival rate for patients (I, 85%, 79%, 79%; II, 89%, 74%, 74%; III, 80%, 80%, 80%; IV, 84%, 75%, 75%, respectively) and primary liver allografts (I, 69%, 69%, 69%; II, 72%, 72%, 63%; III, 70%, 70%, 70%; IV, 71%, 57%, 57%, respectively) were not significantly different (P = .98 and P = .83). CONCLUSION: These results demonstrate that OLT can be effectively performed on infants of all ages and that OLT should not be delayed because of age.

Preliminary experience with split liver transplantation.

BACKGROUND: The purpose of split liver transplantation is to alleviate the organ shortage for patients with end-stage liver disease. The procedure, however, has not gained wide acceptance. This is related not only to the complexity of the procedure but also to poorer results and the complications reported to be associated with the technique. STUDY DESIGN: We report 12 split liver transplantation procedures, seven in children and five in adults. Selection criteria were the same as those for whole-size liver transplantation. Patient and graft survival as well as complications were analyzed. Results were analyzed by Wilcoxon life tables. RESULTS: Patient and graft survival rates are 91.6 and 75 percent, respectively. One patient died at 2.5 months after transplantation because of lymphoproliferative disease. Another had acute vanishing bile duct syndrome and required retransplantation at 1.5 months. One patient had retransplantation because of hepatic artery thrombosis. Bile leaks occurred in two patients and hemothorax in one patient. CONCLUSIONS: Our results indicate that split liver transplantation has become a more acceptable method of hepatic transplantation and should be encouraged. Several guidelines can enhance success rates.

The use of intrapleural clonidine for postoperative pain control.

While the potent analgesic properties of clonidine, a centrally-acting antihypertensive agent, in humans is well described, its analgesic effect when administered into the pleural cavity is largely unknown. We have used intrapleural clonidine as a primary analgesic agent for postoperative pain control in two patients who had undergone cholecystectomy. Clonidine was instilled into the pleural space at the end of the operation via a silastic catheter placed through the seventh intercostal space. Oral pain medications were resumed within 48 hours after removal of the intrapleural catheter. In both patients, there was a substantial improvement in pulmonary function correlating with adequate pain control. No complications were noted secondary to the use of intrapleural clonidine. We conclude that intrapleurally administered clonidine is sufficient to provide adequate postoperative analgesia following abdominal surgery.

Esmolol for hypotensive anesthesia in middle ear surgery.

This study was performed to investigate the efficacy of esmolol, an agent used in hypotensive anesthesia for middle ear surgery. We compared 20 ASA I-II patients to 20 controls in whom we administered routine anesthesia. All patients were premedicated with intramuscular 0.05 mg/kg atropine, 1 mg/kg pethidine and 25 mg promethazine. Anesthesia was induced with 0.004 mg/kg fentanyl and 5 mg/kg thiopental sodium. Succinylcholine 1.5 mg/kg was administered to facilitate intubation. Isoflurane, nitrous oxide, oxygen, 0.08 mg/kg vecuronium bromide and controlled ventilation were used for anesthetic maintenance. Before the controlled hypotensive period, nitrous oxide was discontinued and an esmolol infusion started. We registered hemodynamic values (via noninvasive and invasive radial artery cannulation), central venous pressure, electrocardiography, body temperature, end-tidal carbon dioxide levels, periferal oxygen saturation, and arterial blood gas analysis. Mean infusion rate of esmolol was 330 +/- 10 micrograms/kg/min. We found significant decreases in systolic blood pressure (28.7%), mean blood pressure (26.5%) and diastolic blood pressure (33.4%). The operative field was virtually bloodless. Hemodynamic values recovered to normal or to within -12.45% of normal at the end of intravenous esmolol infusion. During the postoperative period, no side effects were observed. In conclusion, esmolol is an appropriate hypotensive agent for patients undergoing middle ear surgery under hypotensive anesthesia because it yields no side effects, it is easy to control administration and it provides the desired degree of hypotension without complications.

3-substituted piperazinomethyl benzoxazolinones. Analgesic and anti-inflammatory compounds inhibiting prostaglandin E2.

Fourty-three new benzoxazolinone derivatives having a piperazinomethyl group at the third position of the ring were synthesized by using appropriate benzoxazolinones and 4-substituted piperazines via a Mannich reaction. The structures of the compounds were elucidated by spectral data and microanalyses. Analgesic activities were evaluated by a modified Koster test. All compounds, except 7, 14, 21, 32, and 41, showed analgesic activity higher than that of acetylsalicylic acid. The compounds were also screened for their anti-inflammatory activity using a carrageenan paw edema test, and those exhibiting high anti-inflammatory activity were investigated for their ability to inhibit prostaglandin E2 induced paw edema. The results of anti-inflammatory testing indicated that most of the compounds were more active than indometacin. Ulcerogenic activities of the compounds were also studied and no gastrointestinal bleeding was observed at the 100 mg/kg dose level.

Some new benzoxazolinone derivatives with analgesic and anti-inflammatory activities.

Fourteen new 6-acyl-2-benzoxazolinone, ethyl-(6-acyl-2-benzoxazolinone) acetate and (6-acyl-2-benzoxazolinone-3-yl) acetic acid derivatives were synthesized, and their physical properties and UV absorption data were determined. Their chemical structures were elucidated by IR, 1H-NMR and elemental analysis. The analgesic activities of these compounds were investigated by a modified Koster's test. It was shown that the respective activities of compounds 1-4 and 10-14 were higher than that of acetylsalicylic acid. Therefore, they were screened for additionally anti-inflammatory activities using the carrageenan mouse paw edema test. The compounds were further screened for their ability to inhibit prostaglandin E2 (PGE2) induced paw edema and compared to indometacin. Compounds 12 and 13 were very potent in inhibiting PGE2 induced edema.