Acute cellular rejection monitoring after intestinal transplant: utility of serologic markers and zoom videoendoscopy as support of conventional biopsy and clinical findings.

Acute cellular rejection (ACR) episodes in intestinal transplant recipients are diagnosed by histologic and clinical findings. We have applied zoom video endoscopy and the use of serologic markers granzyme B (GrB) and perforin (PrF) to monitor rejection together with conventional tools. Seven hundred eighty-two blood samples (obtained at the time of the biopsy) collected from 34 recipients for GrB/PrF upregulation were positive among 64.9% of ACRs during a 3-year follow-up. Considering only the first year results posttransplantation, it reached 73.1% of rejection events. Zoom videoendoscopy was used by our group in 29 recipients of isolated intestine (n = 24) or multivisceral transplantations (n = 5) to enable observation of villi and crypt areas. From more than 270 procedures, 84% of the zoom findings agreed with the histologic results, namely, a specificity of 95%. In fact, during ongoing ACR, villi were altered in 80% of cases. Both procedures were helpful to support conventional histologic findings and clinical symptoms of ACR in intestinal transplant recipients.

New model of liver regeneration induced through use of vascular endothelial growth factor.

INTRODUCTION: Vascular endothelial growth factor (VEGF) is an endothelial cell mitogen. The objective of this study was to verify the proregenerative effects of VEGF in an experimental model of acute liver failure. MATERIALS AND METHODS: Sixty four rats that underwent intraperitoneal injection of carbon tetrachloride (CCl(4)) were randomly divided into two groups: group B animals received intravenous injection of VEGF(164) 1 hour following CCl(4) poisoning. Group A hosts were untreated. To obtain daily liver function tests (LFTs) and histological samples, on each day up to 8 days we sacrificed four rats in each group. RESULTS: The laboratory examinations showed notable alteration of LFTs in group A, while group B revealed only slight changes. The histological examination showed greater liver damage in group A compared with group B. CONCLUSION: Our results suggest that administration of exogenous VEGF protects the liver from CCl(4)-induced acute hepatic failure. Further studies are underway to assess whether exogenous VEGF is effective in other liver injuries.

[Innovative use of the vascular endothelial growth factor in an experimental model of acute liver failure]. / Utilizzo innovativo del fattore di permeabilità vascolare in un modello sperimentale di insufficienza epatica acuta.

Vascular Endothelial Growth Factor (VEGF) is an endothelial cell mitogen and an important stimulator of sinusoidal endothelial cell proliferation. The aim of this research was to study the effects of exogenous VEGF in a rat model of acute liver failure. The study was conducted on 64 rats (240-300 g). All rats underwent intraperitoneal injection (5 ml/kg) of 25% carbon tetrachloride (CCl4) and 75% paraffin oil. This dosage of CCl4 was devised to induce nonfatal acute liver failure with spontaneous recovery in 7 days. The animals were randomly divided into 2 groups. Group B animals underwent i.v. injection of 200 ng of VEGF165 one hour following intra-peritoneal injection of CCl4. To obtain daily liver functional tests (LFTS) and histological liver samples, 4 rats in each group were sacrificed daily up to 8 days. In group A, the liver histology showed massive periportal hepatocyte necrosis associated with portal lymphocytic infiltrates. The peak of the damage was documented at 72 hours following CCl4. Group B showed minimal necrosis, moderate periportal edema and a minimum periportal steatosis. At 48 hours steatotic changes had disappeared and the periportal edema was resolving. LFTs demonstrated severe liver damage in rats in group A. In group A the peak AST (mean 322.5 IU/L) and ALT (mean 250.25 IU/L) were recorded at 72 hours. In group B, at 72 hours the mean AST was 137 IU/L (normal < 95 IU/L) and ALT 68 IU/L(normal < 45 IU/L). The maximum levels of AST and ALT, in group B, were 152.3 IU/L and 72.3 IU/L, at 24 hours. According to our results exogenous VEGF successfully protects the liver from CCl4 induced acute liver failure. Further studies will demonstrate if exogenous VEGF can be effective in other liver injuries.

Development in diagnosis and treatment of hepatic echinococcosis in a surgical department of a Mediterranean centre over a 20-years period.

Liver echinococcosis is an endemic disease in some areas of the world like Middle East and is a serious problem both from social-economic and clinical-therapeutical stand-points in other areas like Mediterranean regions. We report our experience on hepatic echinococcosis diagnosis and treatment over a 20-year period. In this retrospective study we have reviewed 89 patients affected by hepatic hydatidosis who underwent surgery in our Unit (between November 1975 and October 1995). Patients were divided into two groups: group A including 65 patients (30 males and 35 females) operated on between 1975 and 1988 and group B including 24 patients (11 males and 13 females) operated on between 1989 and 1995. Main outcome measures reported were recurrence of echinococcosis, association with surgical procedure, complications, diagnostic trial. In group A we performed 41 marsupializations, 20 subtotal pericystectomies and 4 total pericystectomies; while 14 total pericystectomies and 10 liver resections were performed in group B. Postoperative hospital stay was of 30 days for group A patients and of 18 days for group B. A single death occurred in group A. Recurrences occurred in group A only (11 cases equal to 17%) and were treated with total pericystectomies (8 cases) and liver resections (3 cases). Our study shows the development of diagnostic procedures trial during the 20-year period and the different surgical approaches between the two groups. Nevertheless we believe that surgical procedures should be tailored to each patient avoid H high surgical risk due to the benign nature of the disease.

[Unreliability of the lidocaine test as a prognostic indicator of acute liver failure: an experimental study in swine]. / L'inattendibilità del test alla lidocaina come indice prognostico nell'insufficienza epatica acuta: studio sperimentale nel suino.

It has been reported, in the recent literature, that fifteen minutes lidocaine-MEGX (monoethylglycinexylidide) test can also be used in case of acute hepatic failure because in these conditions the test allows a rapid evaluation of the hepatic damage, uneffected by te infusion of liquid or fresh plasma which can alter conventional laboratory parameters. The Authors have demonstrated, in a experimental model, the unreliability of the lidocaine-MEGX test as measure of functional hepatic damage in the early stages of an acute liver failure. The slight decrease of the rate of the MEGX test in these animals submitted to one-stage hepatic devascularization suggests that the hepatic failure is not so early detected by this specific liver function test. Accordingly, the 15' MEGX test should not be used as isolated discriminatory measure to detect an early hepatic failure following fulminant hepatitis or an early hepatic insufficiency as a result of extensive liver resection.

Monoethylglycinexylidide (MEGX) test in patients with different liver diseases.

We have studied the levels of the MEGX test in a heterogeneous group of 50 patients with chronic liver disease and with hepatic tumours and we have compared it with the routine LFTS commonly used to assess liver function and with the Child-Pugh Classification system. Our results demonstrate a statistically significant relationship between MEGX levels and prothrombin levels, and between MEGX and alkaline phosphatase and a highly significant relationship between MEGX and cholinesterase. In the group of patients with cirrhosis we found a statistically significant difference amongst the MEGX levels in the 3 classes of the Child Classification system. The MEGX test is a good index in evaluating hepatic function and it is also quick and easy to perform and capable of determining residual liver function. The test can also be used for preoperative assessment in patients with focal hepatic lesions, especially in those with a previous history of cirrhosis, and in patients with functional hepatic disease.

[Primary carcinoma of the medium and distal third of the biliary tract. Personal experience in diagnosis and treatment]. / Carcinoma primitivo del terzo medio e distale della via biliare principale. Diagnosi e trattamento nella nostra esperienza.

A group of 36 patients, observed between 1985 and 1995, with primary carcinoma localized in the medium and distal third of biliary tract is presented. Sixteen patients (44.4%) have undergone radical surgical treatment and the other twenty (55.5%) received a palliative procedure with an average survival of 33.7 months and 8.8 months for the first and second group respectively. The actual location of the tumor was obtained by ERCP and its final stadiation occurred during operation mainly trough intraoperative ultrasonography. The preoperative biliary drainage led to a better postoperative outcome and to a better prognosis. In the case where the tumor was localized only in the third medium of the biliary tract, a limited resection of the biliary tract with Roux's reconstruction was carried out. Otherwise in the cases where the lesion was localized in the border between the medium and distal third and in the distal tract, a duodenocephalopancreasectomy was performed. Even if this is a group of lesions with a poor prognosis, when it is possible to have an early diagnosis it is necessary to carry out an aggressive surgical treatment considering the higher percentage of survival compared to any other palliative procedure.

[Giant cavernous angioma of the liver]. / Angioma cavernoso gigante del fegato.

The authors report on their experience with a case of liver hemangioma; after exploring the trade-off between the risk and expected benefit from resection of giant liver hemangioma, because of this searched literature for studies of with rupture. Controversy persists regarding management of these lesions with the development of non invasive modalities treatment, such as use of embolizing agents; Elective surgery can be performed, such as treatment resective, according to the size of the hemangioma.

[Congenital dilatation of the common bile duct in an adult]. / Dilatazione congenita della via biliare principale nell'adulto.

The Authors present a case of congenital dilatation of the common bile duct in adult life, selecting this lesion from the cystic dilatations of biliary tract group. The type I of biliary tract cystic dilatations is, in fact, considered a clinical-pathological situation apart, that, because of his frequence and his peculiar characteristics especially present in the adult, puts particular problems regarding his arrangement an treatment. The most recent aspects of etiophatogenetic and therapeutic problems of this lesion are treated. The increased risk of neoplastic degeneration in the adult, the recognition of an anomalous pancreaticobiliary duct junction as etiophatogenetic fondamental cause and the necessity of a radical exeretic treatment in in opposition to the old therapheutic orientations are especi-5ally considered.

[Complications of the anterior resection of the rectum]. / Le complicanze della resezione anteriore del retto.

The Authors report their experience, referred to the last 10 years (1980-1989), concerning 169 cases of anterior resection of the rectum. Manual and mechanical anastomoses were performed in 83 and 86 cases, respectively. Immediate and long-term complications are evaluated considering the type of anastomosis used, while results are correlated to the stage of the tumor.