Torque Teno Virus--cause of viral liver disease following liver transplantation: a case report.

Torque Teno Virus (TTV), a nonenveloped human virus of the Circoviridae family, is hepatotropic, causing liver damage, cirrhosis, and, rarely, fulminant hepatitis. It prevails in 10% to 75% of blood donors due to environmental differences, independent of chronic hepatitis B virus (HBV)/HCV hepatitis, cryptogenic cirrhosis, alcoholic cirrhosis, and in fulminant hepatitis non-A-G. Reports about the efficacy of clinical alpha interferon are rare. In July 2007, a 65-year-old man who was serologically negative for A-E viruses presented with acute liver failure due to a ruptured hepatic artery aneurysm and underwent orthotopic liver transplantation (OLT). Immunosuppression was based on cyclosporine and steroids. At postoperative day 20, there was persistent hypertransaminasemia with otherwise normal liver function. A percutaneous hepatic biopsy documented pattern suggestive of a viral etiology. Multiple tests for hepatotropic viruses in the donor and the recipient from the pre- and post-OLT periods remained negative. Only the TTV qualitative test, assessed by polymerase chain reaction (PCR) on patient sera, was positive. Immunosuppressive therapy was not changed; no antiviral therapy was undertaken. At 6 months posttransplantation, transaminase levels spontaneously normalized and the clinical situation was unchanged. No complications were observed; the patient is in good clinical condition. No graft rejection was observed. In histologically proven non-A-E viral hepatitis, it is important to consider TTV as an incidental pathogenic agent. It may be useful to extend virological tests to TTV among transplant recipients and donors and to gain further knowledge about this virus.

Sirolimus therapy in liver transplant patients: an initial experience at a single center.

Sirolimus (SRL) is an mTOR inhibitor that has been shown, in contrast to calcineurin inhibitors (CNI), to inhibit cancers in experimental models. Since February 2005, we introduced SRL in liver transplant patients in group a, in whom the primary disease was hepatocellular carcinoma (HCC) associated with hepatitis B virus (HBV), hepatitis C virus (HCV), alcoholic or autoimmune liver cirrhosis, and group b, HCC-negative patients who developed posttransplantation cancers de novo. Of 18 patients in group a, 11 received SRL ab initio (subgroup a1), starting for 10 patients at 66.1+/-29.2 days after surgical healing and after 10 days in 1 case; the remaining 7 patients (subgroup a2) received SRL at 31.2+/-24.2 months. Three patients in group b, included 1 with Kaposi's sarcoma, 1 with bladder cancer, and 1 with thyroid cancer. In this group, SRL was introduced at 80.8+/-40.4 months. In all patients but one, who received a single 5 mg loading dose, SRL was started at 2 mg/d and adjusted to 6 to 8 ng/mL blood levels. CNI drugs, present as primary therapy, were gradually tapered to low levels and eventually stopped. The following observations were drawn from this initial experience: (1) 4/21 (19.0%) patients had to discontinue SRL because of early and late side effects: thrombocytopenia (n=2) and headache with leukopenia and leg edema associated with knee joint arthralgia (n=2); (2) 14 patients (11 in group a and 3 in group b) are still on SRL monotherapy; (3) 1 HCC recurrence and 1 de novo pancreatic adenocarcinoma were observed at 14 and 16 months, respectively (at the time of transplantation, both patients were beyond the MIlan HCC criteria), and (4) 1 patient, from subgroup a1, died after 99 days due to pneumonitis and possible relation to SRL lung toxicity. In conclusion, SRL appeared to be an effective immunosuppressant that could be used as monotherapy in liver transplant patients. Any conclusion on SRL anticancer effects can only come from randomized large studies after long follow-up.

Preliminary results of liver transplantation for hepatocellular carcinoma among allocation organ policy strategies, neoadjuvant treatments, and intention-to-treat analysis.

We retrospectively evaluated the impact of our strategy for patients with hepatocellular carcinoma (HCC) according to an intention-to-treat analysis and drop-out probability. We evaluated only patients within the Milan criteria. We analyzed the outcomes of neoadjuvant strategies for HCC, organ allocation policy, and systematic application of strategies to increase the deceased donor pool as the current tendency to expand transplantability criteria for those patients. Kaplan-Meier survival probability rates at 1, 3, and 5 years according to an intention-to-treat analysis were 87.02%, 74.53%, and 65.93% for transplanted patients (n=108), and 50%, 14.29%, and 14.29% for the excluded or waiting list group (n=13), respectively (P< .0001). Drop-out risk at 3, 6, and 12 months was 2.40%, 8.59%, and 16.54%, respectively. During the same period, the mortality probability rates at 3, 6, and 12 months among patients without HCC awaiting orthotopic liver transplantation (OLT) were 3.60%, 9.50%, and 18.34%, respectively. Drop-out rate was lower among patients treated before OLT (P< .0001). On the basis of the neoadjuvant treatment results to reduce drop-out risk, we suggest avoiding the high priority for the HCC cohort, particularly within the first 6 months from entrance on the waiting list, because this approach can reduce the chances of patients with end-stage liver disease (ESLD) alone.

Simultaneous liver-kidney transplantation for glycogen storage disease type IA (von Gierke's disease).

INTRODUCTION: Glycogen storage disease type Ia (GSDIa) is due to the deficiency of glucose-6-phosphatase activity in the liver, kidney, and intestine. Although significant progress has been achieved in the management of patients with GSDIa, complications still emerge. The potential for development of liver adenomatosis and kidney failure makes these patients candidates for simultaneous liver-kidney transplantation (SLKT). Herein, we describe such a transplantation in a patient affected by this rare storage disease. METHODS: A 25-year-old female patient with GSDIa developed hepatic adenoma and kidney failure despite dietary therapy. The patient underwent an SLKT from a cadaveric donor. RESULTS: The operative time was 8 hours without hemotransfusion. Only a transitory lactic acidosis was observed. Laboratory results normalized on postoperative day 7. The patient was discharged on postoperative day 9. After 4 months, the patient is in good condition with well-functioning kidney and liver allografts. CONCLUSION: Patients with end-stage renal disease secondary to GSDIa should be considered for SLKT, especially when the disease is in an early stage.

Portal vein pressure and graft oxygen consumption monitoring during liver transplantation.

UNLABELLED: Abnormal splanchnic circulation (ASC) is often detected too late, when hepatic circulation is already irreversibly compromised. If we could detect surgical or metabolic problems early after graft reperfusion, we might be able to correct them immediately before the damage becomes irreversible. The aim of this study was to determine if ASC can be predicted early after liver transplantation (LT) using portal vein pressure measurements and graft oxygen consumption monitoring. PATIENTS AND METHODS: Twenty-patients (13 men, 7 women of mean age 46 years) undergoing LT with the piggyback technique for hepatitis C virus (HCV)/hepatitis B virus (HBV)-related cirrhosis were retrospectively divided in two groups. Group A (16 patients), in which LT was successful, and group B (4 patients) in which LT was unsuccessful because of primary nonfunction (2 patients), infrahepatic portal vein thrombosis (1 patient), or hepatic vein kinking (1 patient). We then compared the portal blood pressure values and the prehepatic and posthepatic oxygen content difference (p-pDO(2)) before portal clamping; at the end of anhepatic phase; 5, 15, and 25 minutes after portal vein (PV) reperfusion; and 5, 20, 40, and 100 minutes after hepatic artery anastomosis. RESULTS: Early after graft reperfusion; portal pressure decreased to levels lower than that at baseline in group A, but remained high until the end of surgery in group B. At the end of surgery, p-pDO(2) increased more among group B than group A. CONCLUSION: ASC, specifically an increased PV resistance, can be predicted early after LT by portal vein pressure measurements and graft oxygen consumption monitoring.

Effect of zafirlukast on methacholine and ultrasonically nebulized distilled water challenge in patients with mild asthma.

BACKGROUND: Bronchial asthma is a chronic inflammatory disease characterized by airway inflammation and hyperresponsiveness due to the release of multiple mediators, such as cysteinyl-leukotrienes (cys-LTs). OBJECTIVE: Our study was designed to investigate whether oral pretreatment with zafirlukast (a cys-LTs receptor antagonist) reduces bronchoconstriction against methacholine (MC) and ultrasonically nebulized distilled water (UNDW) challenge in patients with mild asthma. METHODS: Fourteen non-atopic patients (8 males, 20-42 years, forced expiratory volume in 1 s (FEV(1)) 97% SD +/- 0.4) with mild, intermittent bronchial asthma performed a sequential weekly pulmonary function test following challenge with MC or UNDW 2 h after zafirlukast or placebo administration, according to a single-blind method. RESULTS: We found that pretreatment with zafirlukast significantly decreased bronchoconstriction MC (maximum FEV(1) drop -10.75% SD +/- 1.89, p < 0.001) and UNDW induced (maximum FEV(1) drop -12% SD +/- 0.15, p < 0.001), while pretreatment with placebo did not protect patients against FEV(1) drop following MC (maximum FEV(1) drop -33.22% SD +/- 1.42, p < 0.001) and UNDW challenge (maximum FEV(1) drop -30.02% SD +/- 0.4, p < 0.001). CONCLUSIONS: Pretreatment with zafirlukast significantly reduced bronchoconstriction against MC and UNDW challenge in individuals with mild intermittent asthma, indicating that cys-LTs receptor antagonists might be useful as preventive therapy in these patients population.

In situ splitting of a liver with middle hepatic vein anomaly.

In situ liver splitting provides a way to expand the graft pool, minimize cold ischemia time, and improve hemostasis at the cut surface of the graft. Vascular anomalies of the liver may make the splitting procedure very difficult or even impossible to perform. The in situ splitting procedure, performed on a liver with a middle hepatic vein (MHV) anomaly, is described here. The MHV drained directly into the segment III vein within the hepatic parenchyma instead of draining into the left hepatic vein to form the common trunk. In situ splitting was performed during multiorgan procurement from a 33-year-old man who died of isolated cerebral trauma. The MHV was reconstructed on the back table to secure right graft venous drainage using an iliac vein graft. The resultant right graft, segments I and IV to VIII, and left graft, segments II and III, were transplanted successfully into an adult and a child, respectively. The 2 transplant recipients are currently alive with normal hepatic function 20 months after transplantation.

Orthotopic liver transplantation in a young adult (33 years old) using an 84-year-old donor.

Shortage of liver donors and the increasing number of patients on the waiting list for liver transplantation have led to a widening of the definition of liver donor suitability. Although the age limit for liver donors is controversial, current opinion is towards using liver allografts from donors older than 60 years. However, to date only a few cases that showed a good performance of liver graft by donors older than 60 years have been described. In this case report, orthotopic liver transplantation in a 33-year-old patient who received a graft from an 84-year-old donor is presented. A careful evaluation of the conventional donor-related risk factors (hemodynamics, hepatic function and histologic features) was carried out. Moreover, free radical scavenger glutathione was measured before cold ischemia and at the time of reperfusion in hepatic biopsies. After a 1-year follow-up, the recipient exhibits good general conditions and normal liver function values.

Chlamydia pneumoniae DNA detection in peripheral blood mononuclear cells is predictive of vascular infection.

Abdominal aortic aneurysm tissue and peripheral blood mononuclear cells (PBMC) of 41 consecutive subjects undergoing abdominal aortic aneurysm surgery were analyzed by polymerase chain reaction (PCR) for the presence of Chlamydia pneumoniae, Mycoplasma pneumoniae, and Helicobacter pylori DNA. Twenty patients (49%) were positive for C. pneumoniae DNA-16 (39%) in both PBMC and aneurysm tissue, 3 (7.3%) in PBMC only, and 1 (2.4%) in the artery specimen only. Previous exposure to C. pneumoniae was confirmed in 19 (95%) of the 20 PCR positive subjects by C. pneumoniae-specific serology, using the microimmunofluorescence test. None was positive for H. pylori or M. pneumoniae DNA, either in the PBMC or in the artery specimens. In conclusion, carriage of C. pneumoniae DNA is common both in PBMC and in abdominal aortic tissue from patients undergoing abdominal aneurysm surgery. Blood PCR may be a useful tool for identifying subjects carrying C. pneumoniae in the vascular wall.

IAM inferior: significación del infradesnivel del segmento ST T en derivaciones precordiales / Inferior AMI significance of infradesnivel of ST segment in precordials

Según lo descripto en la literatura, los IAM inferiores con infradesnivel del ST en precordiales presentan peor pronóstico, esto debido a mayor extensión del infarto y a la alteración de la función ventricular izquierda. Nos propusimos determinar si nuestra población con IAM inferior presentaba las características descriptas. Revisamos las historias clínicas de 20 pacientes con diagnóstico de IAM de miocardio de cara inferior. Se dividió a la población en 2 grupos. Grupo 1 que no presentaban alteraciones del segmento ST y Grupo 2 pacientes con infradesnivel del ST en precordiales. En discordancia con lo descripto en la literatura los pacientes de nuestra población sin infradesnivel del segmento ST presentaron mayor número de complicaciones, pero las más graves insuficiencias cardíacas y shocks cardigénicos pertenecieron al grupo 2

[Extensive resections in rectal carcinoma. Our experiences]. / Resezioni allargate del carcinoma rettale. Nostre esperienze.

The authors review their experience in the surgical management of rectal cancer. They analyze rectal malignancies and their recurrences from natural history to surgical strategies and survival rates. In particular, the need to perform extended operations in order to offer patients a better prognosis is discussed.

[Aneurysms of the visceral arteries: the diagnostic problems and therapeutic strategies]. / Gli aneurismi delle arterie viscerali: problematiche diagnostiche e strategie terapeutiche.

Intestinal artery aneurysms are a rare clinical condition, usually asymptomatic. However, sometimes they occur as vascular emergency, with a mortality rate of about 75%. Therefore, their occasional diagnosis should be carefully considered as an indication for elective surgery. The authors report their experience in the surgical management of 3 cases of intestinal artery aneurysms respectively involving the splenic, the gastroduodenal and the inferior mesenteric artery. A review of the literature is also presented.

[Intrahepatic jejunostomy by trans-scission approach in neoplasms of the superior biliary confluent (SBC)]. / Intraepatico-digiunostomie per via trans-scissurale per neoplasie del confluente biliare superiore (CBS).

The Authors consider the trans-scission approach as a quick and safe alternative approach for doing intrahepatic bilio-intestinal anastomoses for the surgical treatment of well confined cancers of hepatic hilus (type I and II of Bismuth e Corlette). This approach should be recommended particularly when the presence of anatomical variations makes the hilar approach hazardous.

[Pulmonary metastases. Their diagnosis and surgical therapy]. / Le metastasi polmonari. Diagnosi e terapia chirurgica.

The Authors on the basis of their own experience and scientific literature, study the indications to the surgical treatment of pulmonary metastasis. Surgical treatment usually produces a palliative result, bettering the quality of life. For some other Authors, surgical treatment if there are no local recurrences and metastasis, could produce complete healing.

The contribution of magnetic resonance imaging in a rare ischiatic localization of osteoid osteoma.

The authors present a case of osteoid osteoma (O.O.) localized in the ischiatic ramus, a very rare (incidence varying from 1.2% to 2.7% in the literature) site for this lesion. Of all the diagnostic tests used, including conventional radiography and Computerized Axial Tomography (CT), the information provided by Magnetic Resonance Imaging (MRI) was particularly valuable. MRI permits recognition of the "nidus" of the osteoid osteoma, which usually emits an intermediate signal on T1-"weighted" images, and is more sensitive than conventional radiography or CT, especially when the marked sclerotic reaction around the tumor renders diagnosis with these last two methods difficult.