Tumoral response factors after radiofrequency ablation of hepatocellular carcinoma in cirrhotic liver.

OBJECTIVE: Hepatocellular carcinoma (HCC) ablation by radiofrequency (RFA) is a novel technique with a great variety of methods whose efficacy and predictive factors have not been completely studied. Some of the main predictive factors in this type of treatment are analyzed in the present study. PATIENTS AND METHODS: Ninety-three patients with hepatocellular carcinoma over cirrhosis, and with no indication for surgical resection were treated by RFA. Two different types of electrodes were used for RFA (refrigerated-"Cool-Tip" and perfusion with saline solution, the approach was percutaneous, by laparoscopy or laparotomy. RESULTS: Overall survival at 1, 2 and 3 years was 88, 81, and 76%, with a free-disease survival (FDS) of 66, 31 and 17%, respectively. For tumors less than 3 cm, FDS at 1,2 and 3 years was 74, 44 and 30%, while for more than 3 cm in size FDS was 55, 12 and 0% (p = 0.02). FDS for HCC with one nodule was 70, 36 and 22%, and for more than one nodule it decreased to 50, 17 and 0% at 1, 2 and 3 years, respectively (p = 0.07). Surprisingly, the method employed for RFA has a main influence in FDS, with 0% at 3 years for perfusion electrodes and 26% for cool-tip electrodes at the same period. CONCLUSIONS: In this series, overall survival at three years was relatively high; however, tumoral size, number of nodules and RFS method were independent variables associated with disease-free survival.

[Bacterial translocation in intestinal transplant]. / Traslocación bacteriana en el trasplante intestinal.

OBJECTIVE: To analyse the influence of ceftriaxone on bacterial translocation and survival after small bowel transplantation in an experimental model with large animals. DESIGN: We performed 21 small bowel transplantation in pigs. Group 1 (n = 5): small bowel transplantation (SBT). Group 2 (n = 5): SBT and immunosuppression with cyclosporine, azathioprine and prednisolone. Group 3 (n = 5): SBT and ceftriaxone. Group 4 (n = 6): SBT, ceftriaxone and immunosuppression. SUBJECTS: Minipig of 25-45 Kg body weight. MEASURES: Blood, spleen, liver, and mesenteric lymph nodes for bacterial culture and biopsy of ileum on postoperative days POD 0.3 and 7. RESULTS: Cultures were positive for bacteria in 22% (10/41) before perfusion, and 43% (28/67) post-reperfusion. Groups 1 and 2: cultures were positive for bacteria in 93% (28/30) on POD 3 degrees, and in 100% (30/30) on POD 7 degrees. Cultures were positive for enterobacteria in 80% (24/30) on POD 3 degrees. Groups 3 and 4: cultures were positive for bacteria in 79.5% (33/41) on POD 3 degrees and in 100% (31/31) on POD 7 degrees. Cultures were positive for enterobacteria in 36.5% (15/41) on POD 3 degrees. Early mortality (before POD 7 degrees), not related with technical complications was 50% (5/10) in groups 1 and 2 and 0% (0/11) in groups 3 and 4. There were no differences with the use of immunosuppression. CONCLUSIONS: Ceftriaxone could decrease bacterial translocation (especially enterobacteria), and early mortality post-small bowel transplantation in pigs.

Hepatectomy including more than half of liver volume with intermittent portal triad occlusion.

INTRODUCTION: Liver resections over 50% of hepatic volume can be achieved with a low morbi-mortality, although occasionally they are followed by severe complications. Postoperative evolution and complications after this type of hepatic resections with intermittent occlusion of the portal triad have been studied. PATIENTS AND METHODS: 13 right hepatectomies, 5 enlarged right hepatectomies and 2 enlarged left hepatectomies were performed consecutively, with intraoperative ultrasound evaluation and intermittent portal triad occlusion. RESULTS: Maximum time of continuous hepatic hilum occlusion was 15 minutes, with a mean isquemia time of 25 +/- 8.6 minutes. Peak of disturbance of hepatic function was at 24 hours and recovered totally at 7th postoperative day. Nine of the 20 patients (45%) did not need intraoperative transfusion and the average of transfusion was 1.8 +/- 1.9 blood units. Four biliary leaks (20%), with no severe hepatic disfunction were observed during postoperative period, and there was no hospital mortality. CONCLUSIONS: Intermittent portal triad occlusion during hepatic resections in more than 50% of liver volume is a safe surgical maneuver.

[Resection of recurrent hepatocarcinoma on a transplanted liver]. / Resección de hepatocarcinoma recidivante sobre hígado trasplantado.

Recurrence of hepatocellular carcinoma is rarely treated by surgical resection and has not been reported in the main series of liver transplantation. In this paper we present the case of a patient transplanted for hepatocellular carcinoma on cirrhosis who developed a tumoral recurrence in the transplanted liver four months later. The new tumor was removed by hepatectomy and the patient is free of tumor 24 months after resection. Surgical resection should be considered a treatment of tumoral recurrence after liver transplantation as is done after hepatectomy.

[Early and late results of orthotopic liver transplantation]. / Früh- und Spätresultate nach orthotoper Lebertransplantation.

Between 4/1986 to 1/1989, 74 orthotopic liver transplantation were performed in 62 patients (62 first liver transplants, 10 as second graft and two as a third graft); 57 in adults and 17 in children. The main indication for the operation was liver cirrhosis (61.4%) (the most frequent etiology was alcoholic cirrhosis, 28.5%). Six cirrhotic patients had a hepatocarcinoma (9.6%). Two received a liver and kidney transplant due to terminal renal insufficiency and hemodialysis. The most frequent indication in children was biliary atresia (33.3%). Six patients had a fulminal liver failure (9.6%). AB0 blood group compatibility was identical in 87.5%, compatible in six and incompatible in three patients. Total orthotopic liver transplantation was performed in 67 patients, and size-reduced liver was indicated in 7 patients. Extracorporeal veno-venous bypass was used in adults but never in children. In 93.1% of the transplants a single hepatic artery was anastomosed to the recipient and in 6.9% a double anastomosis was performed. In 62.5% of the patients a end-to-end choledocho-choledochostomy was performed and in 34.8% hepatico-jejunostomy was indicated. Three months postoperative mortality rate was 12.9%. Arterial stenosis and thrombosis were the most frequent complication.

Transplante hepatico: opcao terapeutica do trauma hepatico / Liver transplantation: a therapeutic option in the liver trauma

Um paciente com traumatismo hepatico consequente de um acidente automobilistico foi submetido a transplante hepatico como unica alternativa de tratamento. O transplante foi indicado ao associar-se uma lesao extensa do lobo hepatico direito a uma lesao irreparavel da porta hepatica esquerda. Pacientes com traumatismo hepatico extenso devem ser transferidos a um servico de transplante o mais breve possivel.

Transplante hepatico: experiencia do Hospital 12 de Octubre de Madrid / Liver transplantat: experience of the 12 de Octubre Hospital of Madrid

No periodo compreendido entre abril de 1986 e janeiro de 1989, foram realizados no Hospital 12 de Octubre de Madrid (Espanha), 74 transplantes hepaticos ortotopicos em 62 pacientes (38 do sexo masculino e 24 do sexo feminino). A idade media dos receptores foi de 35,7 por cento anos (limites de 18 meses a 62 anos). A indicacao mais frequente nos adultos foi a cirrose hepatica (61,4 por cento ), sendo que em 10 pacientes (28,5 por cento ) foi de origem etilica. Seis pacientes apresentavam hepatocarcinoma sobre um figado cirrotico (9,6 por cento ). Dois pacientes receberam duplo transplante hepato-renal. A indicacao preferente na idade pediatrica foi a atresia das vias biliares, seguida da insuficiencia hepatica primaria por hepatite fulminante. Foram realizados 68 transplantes totais e 6 parciais (figado esquerdo). Em todos os adultos e em um transplante pediatrico, se instalou o circuito extracorporeo parcial. Em 67 transplante se praticou uma unica anastomose arterial (93,1 por cento ) e nos cinco restantes, foi necessario realizar duas anastomoses independentes. As arterias dos receptores mais frequentemente utilizadas foram a arteria hepatica direita (23,6 por cento ) e a arteria hepatica primitiva (23,6 por cento ). A reconstrucao biliar foi realizada mediante coledoco-coledocostomia em 65,2 por cento dos transplantes. O retransplante foi realizado em 12 ocasioes.

[Role of liver transplant in the treatment of hepatic hydatidosis]. / Papel del trasplante de hígado en el tratamiento de la hidatidosis hepática.

Three patients are reported who had liver hydatidosis that was not resolved by conventional surgery and who eventually underwent liver transplantation. In view of the satisfactory results obtained, with 100% postoperative survival, possible indications for liver transplant in this type of patients are discussed, fundamentally for secondary sclerosing cholangitis, secondary biliary cirrhosis and acute Budd-Chiari syndrome.

Valorizacion de la adaptacion socio-afectiva del paciente con trasplante de higado / Social-afective adaptation assesment of liver transplanted patient

La volorizacion de la adaptacion socio-afectiva del paciente con trasplante hepatico, constituye un parametro fundamental dentro del marco de recuperacion postoperatoria del paciente trasplantado. La reinsercion al medio social-laboral, la recuperacion paulativa de habitos ocupacionales y recreativos, asi como el restablecimiento y la reorganizacion del aparato psico-afectivo conforman, a nuestro juicio, los criterios mas significativos de la evaluacion del "modus vivendi" del paciente que ha recibido trasplante de higado. La remision de la sintomatologia con la normalizacion de la actividad organica, sumado a una calidad de vida adecuada, constituyen el respaldo basico de cualquier intervencion quirurgica

Choledochal cyst resection and reconstruction by biliary-jejuno-duodenal diversion.

From January, 1983 to December, 1986, a total of 9 patients, ranging in age from 2 years and 4 months to 36 years, with choledochal cysts were treated. Symptoms were right upper quadrant pain (n = 9), ascending cholangitis (n = 7), and jaundice (n = 6). A right upper quadrant mass was palpable in 7 patients and gallstones were present in 5 patients. Diagnosis was established by intravenous cholangiogram and ultrasound. The operation was performed through a right subcostal laparotomy. The choledochal cyst diameter ranged from 4.5 to 7 cm. The cyst and the common duct were dissected from the hepatic artery and portal vein. The choledochus was sectioned above the duodenum and the distal end was closed by interrupted sutures. The common duct was divided below the hepatic confluence and the diameter enlarged by longitudinal section of the left hepatic duct. A 30-cm-long segment of isolated jejunum was passed through the transverse mesocolon to the right of the middle colic vessels and behind the duodenum and then interposed between the hepatic confluence and the second portion of the duodenum. Biliary-jejunal anastomosis was performed in 1 layer with interrupted absorbable stitches. No mortality or serious complications occurred during follow-up (1-4 years). No cholangitis, fever, or pain have developed. All patients were studied postoperatively by biochemical test, ultrasonography, Tc 99m DISIDA, and barium meal swallow. Good liver function and biliary excretion, and absence of duodeno-jejuno biliary reflux were demonstrated.

[Reduction of transfusion needs by the early introduction of venovenous bypass in liver transplant]. / Disminución de las necesidades transfusionales mediante la introducción precoz del by-pass venovenoso en el trasplante hepático.

A study was made of 44 patients who underwent liver transplant, distributed into three groups: Group A: patients who had ample liver dissection before entering bypass. Group B: patients who entered bypass after dissection of the hepatic hilum and prior to any other dissection; bypass time was prolonged for meticulous hemostasia. Group C: patients with perfectly defined hemodynamic problems, not secondary to bleeding, during the anhepatic phase. Preoperatively the three groups were homogeneous as regards clinical situation. During the operation a significantly larger transfusion volume (p less than 0.01) was administered in group C during phase II (70.1 +/- 27.2 ml/kg/h), phase III (32.6 +/- 9.6 ml/kg/h) and throughout surgery (32.7 +/- 10.3 ml/kg/h) than in the other two groups. Group B received a smaller transfusion volume during phase II (14.6 +/- 8.1 ml/kg/h), phase III (12.7 +/- 5.5 ml/kg/h) and throughout surgery (11.6 +/- 4.9 ml/kg/h) than the other two groups (p less than 0.01). The transfusion needs of group A were 28.4 +/- 15.6 ml/kg/h in phase II, 26.8 +/- 17.1 ml/kg/h in phase III and 21.2 +/- 11.2 ml/kg/h throughout surgery. The duration of the anhepatic phase was significantly shorter (p less than 0.01) in group A (1 h 10' +/- 10) than in (1 h 50' +/- 10) and C (1 h 40' +/- 45'). In the postoperative period a higher mortality was associated with group C (37.5%) and a lower mortality with group B (3.33%), the mortality of group A being 16.6%. The differences were statistically significant with p less than 0.01.

[Indications and results of surgical treatment of cavernous hemangioma of the liver]. / Indikationen und Resultate der chirurgischen Behandlung von cavernösen Hämangiomen der Leber.

Over a period of 6.5 years, 29 patients with liver hemangiomas have been examined. In 8 patients, the most frequent symptom was pain; in 11, a tumor was found. The diagnosis was made by means of scintigraphy with 99mTc, followed by real-time sonography, computed tomography using a contrast medium, and selective arteriography. In 16 patients (15 women, 1 man), the tumor radius was more than 6 cm and in 9 of these, more than 10 cm. In 3 patients, a left lobectomy was carried out, and in 5 a right lobectomy; in an additional 5 patients, a extended right lobectomy (three segments excised) was done. In the rest, a medial lobectomy, a segmentectomy on the left side, or a segmentectomy on the right was performed. The only complications observed in the whole series were: pleural effusion (1 case), subphrenic abscess (1), and transitory biliary fistula (1). All hemangiomas with a radius of more than 10 cm should be removed operatively, as should smaller symptomatic hemangiomas and tumors that are not clearly benign.

Biliary and pancreatoduodenal diversion by means of an isolated jejunal loop.

Seven patients suffering from chronic pancreatitis, with dilatation of the duct of Wirsung and obstruction of the intrapancreatic segment of the choledochus, underwent a pancreatic and biliary jejunoduodenal diversion. An isolated jejunal loop was used as a conduit between the bile and pancreatic ducts and duodenum in 3 patients, while in 4 patients separate isolated loops between the duct and duodenum were fashioned. The postoperative period passed without incident. All the patients were symptom free 3 months after operation.