Alveococcosis of the liver - strategy of surgical treatment with special focus on liver transplantation.

BACKGROUND: Echinococcosis is a zoonosis caused by infestation with any of 4 (of the 16) members of the Echinococcus genus, namely Echinococcus granulosus, Echinococcus multilocularis, Echinococcus oligarthus, and Echinococcus vogelii. The aim of this retrospective analysis was to present the outcomes of patients undergoing liver resection and liver transplantation (LT) for E. multilocularis infection. METHODS: A total of 44 patients who underwent surgical treatment of E. multilocularis infection in the period between 1989 and 2014 were included in the study cohort and retrospectively analyzed. RESULTS: LT was performed in 22 patients (50.0%), including 4 of 26 patients undergoing initial non-transplant management. Non-transplant procedures comprised liver resection in 23 patients (88.5%), diagnostic laparoscopy in 2 (7.7%), and left adrenalectomy in 1 patient (3.8%). Post-transplantation survival rates were 90%, 85%, and 75% at 1, 5, and 10 years, respectively. CONCLUSION: In conclusion, LT for E. multilocularis infection is a safe and effective treatment method.

Angiogenic activity of sera from interstitial lung disease patients in relation to clinical and radiological changes.

OBJECTIVE: Clinical symptoms and radiological changes are useful in monitoring patients with interstitial lung diseases (ILD). Neovascularization participates in the pathogenesis of idiopathic pulmonary fibrosis and other ILD. The objective of the study was to examine the relationships between angiogenic activity of sera from ILD patients and clinical or radiological status. MATERIAL AND METHODS: Serum samples were obtained from 83 patients with sarcoidosis, 31 with idiopathic pulmonary fibrosis (IPF), 29 with hypersensitivity pneumonitis (HP), 16 with collagen diseases with pulmonary manifestation (CD), 13 with scleroderma (SCL), 14 with Wegener's granulomatosis (WG), 12 with pulmonary Langerhans cell histiocytosis (HIS), 12 with pneumoconiosis (PNC), 10 with drug-induced lung disease (DLD), 5 with cryptogenic organizing pneumonia (COP), and from 36 healthy volunteers. As an angiogenic test we used a cutaneous angiogenesis assay according to Sidky and Auerbach. Clinical status was evaluated using a special questionnaire. In all patients chest radiographs were performed. RESULTS: The angiogenic properties of sera from ILD differed depending on the clinical diagnosis. The strongest proangiogenic effect was induced by sera from patients with HP (mean number of new vessels 16.8), CD (16.6), sarcoidosis (16.3), IPF (16.2), and PNC (15.7). In the case of DLD (13.2), the effect was comparable to healthy controls (13.5). In contrast, sera from SCL (mean number of the vessels 10.5) and HIS patients (10.8) significantly inhibited angiogenesis compared with controls. The angiogenic activity of sera from patients with hilar or mediastinal lymph nodes involvement was higher than that of sera from patients with lung fibrosis. There were also differences in the serum angiogenic activity in relation to the severity of dyspnea. CONCLUSIONS: The data showed that sera from ILD patients constitute a source of mediators modulating angiogenesis, but the pattern of reaction is different in various diseases. Sera from HP, sarcoidosis, IPF, and CD patients demonstrated the strongest proangiogenic activity. However, sera from SCL and HIS inhibit angiogenesis. Angiogenic activity of examined sera was related to the clinical and radiological changes.

Biliary complications in relation to the technique of biliary reconstruction in adult liver transplant recipients.

UNLABELLED: Biliary complications are known as a weak point of liver transplantation. Their occurrence can be related to the practice of draining the biliary anastomosis performed at the time of transplantation. At our institution, routine of anastomotic biliary drainage was abandoned in June 2004. AIM: We sought to assess the occurrence and character of biliary complications following orthotopic liver transplantation in relation to the technique of anastomosis. MATERIALS AND METHODS: In two groups of transplantees: last 100 transplantations with biliary drainage (48 females and 52 males aged 17 to 64 years) and last 100 transplantations without drainage (52 females and 48 males aged 18 to 67 years). The results of treatment were compared, for biliary complications and their influence on further management. In both groups, the main indications for transplantation were various types of cirrhosis as well as cholestatic diseases. In most cases (167) we performed a cholangiojejunal Roux-en-Y (CBD) end-to-end anastomosis, less commonly (33 cases) hepaticojejunal anastomoses. RESULTS: In the first group, biliary complications (bile leak at the site of drainage, bile leak after T-tube removal, CBD strictures) requiring surgical or endoscopic intervention, occurred in 17% recipients. In one case, the biliary complication resulted in retransplantation. In the second group, biliary complications occurred in 11% patients. None of them caused organ loss. CONCLUSION: Abandoning drainage of the biliary anastomosis has reduced the occurrence of early biliary complications after orthotopic liver transplantation.

Early results of orthotopic liver transplantations using the technique of inferior vena cava anastomosis.

INTRODUCTION: We compared early results of orthotopic liver transplantation (OLT) in adults using the classic versus piggyback technique of inferior vena cava anastomosis. PATIENTS AND METHODS: We analyzed 100 consecutive patients who underwent OLT from 2000 to 2003. Group A included 50 patients operated with the classic technique with venovenous extracorporeal bypass, and group B, 50 patients with the piggyback technique. The age range of the patients in group A was 21 to 63 years (mean, 43.5 years) and in group B, 20 to 65 years (mean, 46 years). The gender F/M distribution in group A was 24/26 and in group B, 28/22. The indications for OLT were acute hepatic failure (8%), chronic liver insufficiency (77%), liver tumors (8%), metabolic diseases (5%), and Budd-Chiari syndrome (2%). The degrees of liver insufficiency evaluated according to the Child classification were A, 18; B, 52; and C, 30 patients. The urgency for OLT on the United Network for Organ Sharing (UNOS) scale was UNOS 1-group A, 2 patients; group B, 7 patients; UNOS 2a-group A, 7 patients; group B, 6 patients; UNOS 2b-group A, 29 patients; group B, 30 patients; UNOS 3-group A, 12 patients; group B, 7 patients. RESULTS: The average cold ischemia time in group A was 530 minutes and in group B, 515 minutes. The average results on the 10th postoperative day: aspartate transaminase (AST)-group A, 52.5 U/L; group B, 54.5 U/L; alanine transaminase (ALT)-group A, 131.5 U/L; group B, 153 U/L; gamma glutyl transpeptidase (GGTP)-group A, 299 U/L; group B, 285.5 U/L; alkaline phosphatase (ALP)-group A, 164 U/L; group B, 150.5 U/L; bilirubin-group A, 4.37 mg%; group B, 2.71 mg%; activated partial thromboplastin time (APTT)-group A, 37.6 seconds; group B, 34.8 seconds; platelets (PLT)-group A, 167 10(2)/mm(2); group B, 171 10(2)/mm(2). The incidence of postoperative complications was 36% in group A; it was 30% in group B. The mean hospitalization times in the surgical department were 17 days in group A and 16 days in group B. CONCLUSIONS: The early results, morbidity and mortality with both applied techniques were similar. Individualization in qualifying the patients for a given operative technique is important. The lower complication rate and reduced treatment cost of the piggyback technique group suggested advantages of this technique when compared with the classical OLT technique.

Orthotopic liver transplantation for fulminant hepatic failure.

This paper presents the results of liver transplantation for fulminant hepatic failure in 31 patients qualified as UNOS-1 class (extra-urgent indication for transplantation), operated from January 1989 to April 2005. Twenty-one patients (61.8%) survived the 3-month postoperative period. Three-year survival rate with good liver graft function was 52.9% (18 patients). Before the transplantation, eight patients (23.5%) underwent hepatic dialysis using Fractionated Plasma Separation and Adsorption (FPSA) with the use of a Prometheus 4008H System. Liver transplantation remains the only life-saving procedure for the treatment of fulminant liver failure, regardless of its cause.

Assessment of early biliary complications after orthotopic liver transplantation and their relationship to the technique of biliary reconstruction.

INTRODUCTION: Biliary complications are known as the weak point of liver transplantation. Their occurrence can be related to the practice of drainage of the biliary anastomosis, the routine use of which was abandoned in June 2004. The aim of the study was to assess the incidence and type of biliary complications following orthotopic liver transplantation in relation to the technique of biliary anastomosis. MATERIAL AND METHODS: We compared the results of two groups of adult liver transplant recipients: group I, recent 50 transplantations with biliary drainage (25 women: 25 men of age range: 17 to 63 years), and group II, first 50 transplantations without drainage (19 women and 31 men of age range, 20 to 65 years). We examined the problem of biliary complications and their influence on the further management of the patients. In both groups the main indications for transplantation were various types of cirrhosis as well as cholestatic diseases. In the majority of cases (n = 86) an end-to-end common bile duct anastomosis was performed and in 14 cases, hepaticojejunal anastomosis. RESULTS: In group I, biliary complications requiring surgical or endoscopic intervention occurred in 10 (20%) recipients. In one case, biliary complications resulted in the need for retransplantation. In group II, biliary complications occurred in only four (8%) patients, none of which caused organ loss. CONCLUSION: Cessation of biliary anastomosis drainage has reduced the occurrence of early biliary complications following orthotopic liver transplantation.

Fatal infection in patients treated for small cell lung cancer in the Institute of Tuberculosis and Chest Diseases in the years 1980-1994.

The study was performed to explore the frequency of infections present at death and infection as the main cause of death (fatal infection - FI) in 845 consecutive patients (pts) treated for small cell lung cancer (SCLC) at the Institute of Tuberculosis and Chest Diseases in Warsaw, in the period 1980-1994. Diagnosis of infection was based on clinical signs and symptoms, the presence of new lesions on the chest X-ray, microbiological tests and/or autopsy examination. All cases of fungal infection, Pneumocystis carinii pneumonia (PCP) and tuberculosis were proved by autopsy and microscopic examination (including special staining). FI was diagnosed if no progression of cancer was noted and no other complications occurred. Infection was present at the time of death in 116 patients (13.7%) and FI was the cause of death in 39 of them (4.6%). Nine patients died from fungal infection, eight from bacterial infection, seven from PCP and two from tuberculosis. In 13 cases the aetiology of infection found at autopsy was not determined. All FI patients received chemotherapy and corticosteroids, 16 of them also had radiotherapy on the tumour and mediastinum. Thirty-two out of 35 patients had leucopenia. The risk of death from infection was greater in patients above 60 years of age. Patients in bad performance status died of infection significantly earlier than others (P<0.05).

Bile duct variations in partial liver transplantations from living-related donors.

The aim of this paper was to present anatomic variations of bile ducts and their effect on the perioperative course of living-related donors in partial liver transplantations in children. Liver fragments for partial transplantation were harvested from 41 related donors. Segments II and III were harvested from 35 and segments II, III, and IV from 6 donors. During the procedure, cholangiography through cystic duct was performed revealing a normal anatomy of the bile ducts in 33 (80.5%) cases. The rest of the donors showed anatomic variations. There was only one case of complications related to the bile duct. The intraoperative diagnosis of anatomic variations allowed for safe partial liver harvesting.

Comparison of the results of liver transplantation for elective versus urgent indications.

The authors present an analysis of early and remote liver transplantation outcomes related to the presence of emergent indications among 196 of the 209 operations performed from 1989 to April 2003; namely 178 elective and 18 emergent transplantations. Perioperative mortality was 15%. The survival rate during the first 12 months was 79.8% and within 3 years 73.5% among patients operated on an elective basis (UNOS 3 and 2B). In contrast, patients with acute liver failure (UNOS 1 and 2A) showed rates of 45%, 50%, and 47%, respectively. Liver transplant outcomes depend primarily on the urgency of an operation. Longterm results are much better among patients operated on electively. Liver transplantation in patients with acute hepatic insufficiency is burdened with a high 45% mortality.

Vascular complications after liver transplantation.

Vascular complications following liver transplantation is reviewed based upon literature data and our own results. Our study conclusions are mostly based on literature data, because our center does not have the liver transplantation experience of other centers worldwide. Thus, we may conclude, that the number and character of complications does not differ from those reported by other centers. The enbloc technique used in liver harvesting minimizes the risk of arterial damage in case of vascular anomalies. Recipient retransplantation is the most effective treatment method in cases of hepatic arterial occlusion. Doppler ultrasound examinations are effective to monitor vascular blood flow in the transplanted liver.

The impact of experience of a transplantation center on the outcomes of orthotopic liver transplantation.

The so-called learning factor has been disregarded for many years in analyzing the causes of surgical complications and post-operative mortality; it is also the case for OLT. In our center until April 2003, 209 OLT were performed in 196 patients. We evaluated the impact of experience of the transplantation team on the outcomes of liver transplantation. Thirty-four patients died (mortality rate, 16%) and 1-year survival rate, 64%. Mortality rates varied during different periods of observation due to increasing experience of the transplantation team. The causes of mortality were assessed for a series of 34 patients: it was 75% at the beginning of transplantation procedures while recent deaths have not recently exceeded 10% of cases.

[Spinal tuberculosis]. / Gruzlica kregoslupa.

The cases of 32-year-old man and 42-year-old women are presented. Their history illustrates difficulties in the diagnosis of tuberculosis of the vertebral column. The patients suffered significant pains in the lumbar region lasting one year. Despite the presence of some abnormalities in lumbar vertebrae on x-rays no examinations were ever performed to establish the diagnosis. Lumbago and osteoporosis were considered as the cause of complaints. Aetiology was confirmed only when patients developed disseminated tuberculosis of the lungs. Antituberculous chemotherapy was successful and brought a fast improvement in general status of the patients.

[Our experience in bronchiolitis obliterans organising pneumonia (BOOP): personal experience]. / Bronchiolitis obliterans orginizing pneumonia--doswiadczenia wlasne.

BOOP is a disease with characteristic histology features which can occur as a secondary lung reaction to the various toxic agents or as a primary idiopathic disease. Idiopathic form of BOOP is a rare disease and may be found in 6-7 patients of 100,000 hospital admissions. We described 3 patients with idiopathic BOOP confirmed by the histologic lung examination. The time from the beginning of symptoms till the microscopical diagnosis ranged from 6 to 12 months. At the beginning of the disease the patients had symptoms compatible with the respiratory infection. In one of the patients the clinical course of the disease had a progressive character. In two patients spontaneous regression of radiological lung lesions was observed. This regression was however only temporary in one of them. In two cases treated by steroids regression of lung lesions was noticed.

[Tuberculosis of the tongue--case report]. / Gruzlica jezyka--opis przypadku.

The case of 56-year-old male with disseminated lesions in the lungs and ulcerations of the tongue is presented. Pathomorphological examination of the tongue ulcerations showed changes typical for tuberculosis. Cultures of 4 specimens of the sputum revealed the presence of Mycobacterium tuberculosis. Antituberculotic drugs (INH, RMP, EMB, PZA) were administered. Complete remission of the tongue ulcerations and partial remission of the lesions in the lungs were observed after 6 weeks of the treatment.

[Diffuse alveolar hemorrhage in Wegener's granulomatosis]. / Rozlane krwawienia pecherzykowe w przebiegu ziarniniakowatosci Wegenera.

Two cases of Wegeners Granulomatosis were presented. In the both cases diffuse alveolar hemorrhage was found.

[Hepatic tuberculosis]. / Gruzlica watroby.

Tuberculosis of the liver can be the only manifestation of the disease or it may be a part of disseminated process. Three cases of liver tuberculosis were presented. In one of them the process was restricted to the liver and the diagnosis was made only at autopsy. In two other cases, tuberculosis of the liver was a part of disseminated process. In one of them the impairment of liver function improved after therapy and in another one, in spite of therapy, the patient died with signs of cardio-respiratory and hepatic insufficiency.

[Tuberculosis found in autopsies done in the Institute of Tuberculosis and Lung Diseases 1972-1991]. / Gruzlica rozpoznana na podstawie badania posmiertnego w materiale Instytutu Gruzlicy i Chorób Pluc w latach 1972-1991.

Between years 1972 and 1991 1500 autopsies were done in the Institute of Tuberculosis and Lung Diseases in Warsaw. Active tuberculosis was found in 119 cases (7.9%). 56 patients died of tuberculosis. Tuberculosis was not diagnosed during life in 37% of all cases and in 39% of that in whom it was the cause of death. Tuberculosis was undiagnosed significantly more often in the years 1982-1991 than in years 1972-1981. Tuberculosis was restricted to the lungs in 60.5% of cases, was found in the lungs and in the extrapulmonary sites in 37.8% and only outside lungs in 1.7%. This is in contrast with official polish statistics. The extrapulmonary tuberculosis was registered in only 4% of cases.

[Infection as a main or additional cause of death in patients treated for small cell lung cancer]. / Zakazenia jako glówna lub dodatkowa przyczyna zgonu u chorych leczonych z powodu drobnokomórkowego raka pluca.

The aim of this study was to analyse the frequency of infection as a cause of death in small cell lung cancer (SCLC) patients. Our material consisted of 845 unselected SCLC patients, 246 women and 599 men, aged 29-78 years, treated between 1980-1994 in the Institute of Tuberculosis in Warsaw. 479 patients had limited and 366 extensive disease. 530 were in good (0-2) and 315 in bad (3-4) performance status. 784 patients died. Autopsy was done in 211 patients. Infection was regarded as a main cause of death in 39 patients (4.6%) and as a coexistent cause in 77 (9.1%). At the time of death from and/or with infection in 16 patients complete remission and in 27 partial remission of cancer was confirmed. The risk of death from and/or with infection was not related to the age and sex or to the performance status of patients and to extension of cancer. The risk of death from and/or with infection in the first 3 months of treatment was however greater for patients in bad performance status and with extensive disease and later (after 3rd months) for patients in good performance status and with limited disease.

[The cause of infection as the main or additional cause of death in patients treated for small cell lung cancer]. / Etiologia zakazenia jako glównej lub dodatkowej przyczyny zgonu u chorych leczonych z powodu drobnokomórkowego raka pluca.

In 116 out of 845 patients treated for small cell lung cancer (SCLC) in the Institute of Tuberculosis and Chest Disease in Warsaw in the years 1980-1994 infection was the main or coexistent cause of death. In 4.1% infection was proved of bacterial origin and in further 6.5% of probable bacterial origin (in the later group cultures were negative or not done but fungal infection, pneumocystosis pneumonia and tuberculosis were excluded on autopsy). In 1.54% infection was of fungal origin, 1.2% patients died of Pneumocystis carinii pneumonia and 0.35% of tuberculosis. The majority of patients who died with and/or from infection had treatment-related leukopenia and 99 of them were treated with corticosteroids. Fungal infection, pneumocytosis and tuberculosis were found more frequently than bacterial infection in patients treated with cumulative dose of prednisone above 2000 mg. 33.62% patients had no symptoms or signs of infection. No connection was found between the absence of symptoms and treatment with steroids or the grade of leukopenia. In all cases infection was recognised very late, in 58 only at autopsy.

[Myocardial infarction as a cause of death in patients treated for small cell lung cancer]. / Zawal miesnia sercowego jako przyczyna zgonu chorych leczonych z powodu drobnokomórkowego raka pluca.

The aim of our study was to assess frequency of death from myocardial infarction in patients (pts) treated for small cell lung cancer (SCLC). 33 out of 845 patients treated for SCLC died from myocardial infarction. All patients were smokers. In 6 patients coexisted hypertension, in 2--diabetes and in 5--obesity. Eight patients have had cardiac disease in anamnesis. All patients were treated with one or more number of cardiotoxic drugs as DDP, VCR or VBL, E, MTX and ADR which are able to cause ischemic heart disease or myocardial infarction. Sixteen out of 33 patients have had radiotherapy of lung tumour. Death from myocardial infarction occurred from 0.5 up till 98.5 months from the beginning of start treatment. Eighteen men died from myocardial infarction in the first year of treatment. Risk of death from myocardial infarction was 15 times greater in men with SCLC than in men of the polish population at the same age and at the same time.