Mucinous cystic neoplasm of the liver with biliary communication: case report and surgical therapeutic option.

BACKGROUND: Mucinous cyst neoplasm of the liver (MCN-L) comprise less than 5% of all cystic liver lesions and is characterized by the presence of ovarian stroma and absence of bile duct communication. CASE PRESENTATION: Here, we discuss a 45-year-old woman who presented with symptomatic liver mass. Diagnostic workup detected a 4.2 × 3.6 cm septate cyst located in segments I, V, and VIII of the liver in communication with the right hepatic duct. An open right liver resection with total bile duct excision and hilar lymphadenectomy was performed. Pathology revealed a multiloculated cyst with lined mucinous epithelium and ovarian-like stroma, consistent with low-grade MCN-L. CONCLUSIONS: This case shows that unusual location and bile duct communication can be present in MCN-L.

Immunosuppression Protocols in Intestinal and Multivisceral Transplantation-A Literature Review.

BACKGROUND: Intestinal transplantation (IT) and multivisceral transplantation (MVT) are curative therapies for patients with intestinal failure and severe complications associated with total parenteral nutrition. High levels of immunosuppression are required to prevent acute cellular rejection (ACR) from the bowel. Studies regarding pre-treatment, induction, and post-transplant therapy have improved graft acceptance, reducing immunosuppression doses and infectious complications. However, the low rate of IT and MVT and the small number of specialized centers have resulted in a limited number of evidence-based immunosuppression protocols. We reviewed immunosuppression in IT and MVT to draw useful conclusions regarding the best protocol strategies for the induction, maintenance, and management of ACR. METHODS: A review was performed using the PubMed database. Articles on immunosuppression protocols in IT and MVT that addressed graft rejection, infection, or survival, published between 2006 and 2022, were selected. RESULTS: A total of 690 articles were selected. Two researchers applied the inclusion and exclusion criteria and selected 14 articles independently. For induction, thymoglobulin, alemtuzumab, and basiliximab are the most frequently used immunosuppressants for induction. Classic maintenance therapy consists of a combination of corticosteroids and tacrolimus. Methylprednisolone with an increased tacrolimus dose is used most frequently to manage ACR. Depending on the receptor response, such as thymoglobulin, infliximab, adalimumab, or bortezomib, other immunosuppressants should be considered. CONCLUSIONS: There have been great advances in IT and TMV immunosuppression. We conclude that the gold standard immunosuppressive protocol is triple therapy, comprising induction with thymoglobulin, maintenance with steroids for a few months, and tacrolimus and mycophenolate therapy. Innovative approaches for treating intestinal rejection episodes with more appropriate drugs, such as infliximab, adalimumab, or bortezomib, are necessary.

Application of the Balance of Risk Score to Liver Transplantation.

BACKGROUND: To evaluate the capacity of BARS to predict 90-day, 1-year, 3-year, and 5-year survival after liver transplantation (LTx). The Balance of Risk Score (BARS), proposed by the Swiss Hepato-pancreato-biliary and Transplant Center, University Hospital Zurich, Switzerland, was conceptualized to determine survival after LTx preemptively. SAMPLE AND METHODS: This was a retrospective observational study on 866 cases of LTx among adults (>18 years) performed within the transplantation program at Hospital Israelita Albert Einstein between January 1, 2010, and December 31, 2015. Cases of loss from follow-up, split-liver transplantation, transplantation from a live donor, and combinations of LTx with transplantation of other organs were excluded. BARS was calculated for each transplantation performed. The survival estimates were accompanied by 95% CIs, and the associations between the variables of interest and the patients' overall survival were evaluated using Cox proportional risk models. Receiver operating characteristic curves and the estimated area under the curve were used with 95% CIs and P values for the equality test on the area at .5. RESULTS: The area under the curve for the 90-day period was 0.725, with a 95% CI from 0.670 to 0.81 and a P value < .001 for the equality test at 0.5. In the stratified analysis, the score of 18 presented the highest sensitivity, taking a minimum specificity of 90%. The BARS >18 gave rise to a significant decline in survival, from 89.7% to 60.4% over the first 90 days, from 83.3% to 56.2% over a 1-year period, from 75.7% to 49.5% over 3 years, and from 72.2% to 43.4% over 5 years. CONCLUSION: The BARS was shown to be reproducible and can be used as a tool for estimating survival among LTx patients. LTx performed on patients with BARS >18 significantly predicts lower survival for such patients.

Pharmacological Modulation of the Ca2+/cAMP/Adenosine Signaling in Cardiac Cells as a New Cardioprotective Strategy to Reduce Severe Arrhythmias in Myocardial Infarction.

Acute myocardial infarction (AMI) is the main cause of morbidity and mortality worldwide and is characterized by severe and fatal arrhythmias induced by cardiac ischemia/reperfusion (CIR). However, the molecular mechanisms involved in these arrhythmias are still little understood. To investigate the cardioprotective role of the cardiac Ca2+/cAMP/adenosine signaling pathway in AMI, L-type Ca2+ channels (LTCC) were blocked with either nifedipine (NIF) or verapamil (VER), with or without A1-adenosine (ADO), receptors (A1R), antagonist (DPCPX), or cAMP efflux blocker probenecid (PROB), and the incidence of ventricular arrhythmias (VA), atrioventricular block (AVB), and lethality (LET) induced by CIR in rats was evaluated. VA, AVB and LET incidences were evaluated by ECG analysis and compared between control (CIR group) and intravenously treated 5 min before CIR with NIF 1, 10, and 30 mg/kg and VER 1 mg/kg in the presence or absence of PROB 100 mg/kg or DPCPX 100 µg/kg. The serum levels of cardiac injury biomarkers total creatine kinase (CK) and CK-MB were quantified. Both NIF and VER treatment were able to attenuate cardiac arrhythmias caused by CIR; however, these antiarrhythmic effects were abolished by pretreatment with PROB and DPCPX. The total serum CK and CK-MB were similar in all groups. These results indicate that the pharmacological modulation of Ca2+/cAMP/ADO in cardiac cells by means of attenuation of Ca2+ influx via LTCC and the activation of A1R by endogenous ADO could be a promising therapeutic strategy to reduce the incidence of severe and fatal arrhythmias caused by AMI in humans.

[Hepatogastric fistula after chemoembolization of liver metastasis: a case report]. / Fistula hepatogástrica após quimioembolização de metástase hepática.

Liver metastases of colorectal cancer are a challenge in current oncology. Less than 5% of untreated patients are alive after 5 years of diagnosis. The only curative treatment is surgical resection, but there are other options for palliative or neoadjuvant treatment such as transarterial chemoembolization. Serious complications after liver chemoembolization are very rare, and one of the possible complications is a liver abscess. We report a case of hepatogastric fistula caused by a liver abscess ten days after the chemoembolization of a liver metastasis. It was treated surgically with left hepatectomy and parcial gastrectomy, with good outcome. There are only a few reported cases of hepatogastric fistula after liver transarterial chemoembolization.

Chronic pancreatitis with ductal stones in the pancreatic head treated by surgery: a case report.

Pancreatic duct stones are direct sequelae of chronic pancreatitis (CP) and can occur in ∼50% of patients. Selection of the appropriate treatment method for pancreatic duct stones depends on location, size and number of stones. We present a patient with upper abdominal pain and weight loss for the previous 3 months. Diagnostic workup detected a chronic inflammation of the pancreas with stone in the main pancreatic duct and a nodular lesion in the head of the pancreas. Endoscopic retrograde cholangiopancreatography was performed without success. Given the rise in incidence and prevalence of CP, the potential complications and high mortality rate, it is imperative that physicians understand the risk factors, disease process and management of this disease. Pancreaticoduodenectomy in patients with CP is a feasible option for the treatment of focal cystic lesions to the head of the pancreas associated to pancreatic stone in selected cases.

Encapsulating Peritoneal Sclerosis in a kidney transplant recipient - Case Report.

Encapsulating Peritoneal Sclerosis (EPS) is a severe and rare condition frequently associated with peritoneal dialysis, characterized by bowel obstruction, with lethal consequences in 20% of the patients. The disease presents as a mass of fibrous tissue encapsulating visceral organs that may potentially compromise digestive tract function. This report describes the case of a patient under peritoneal dialysis (PD) due to chronic kidney disease secondary to focal segmental glomerulosclerosis diagnosed with EPS. The patient had undergone two living-donor kidney transplant procedures. Surgical techniques and clinical measures employed to unravel bowel obstruction are described, which have been shown to ameliorate EPS secondary complications. Parenteral nutrition has significantly contributed to afford adequate nutrition, improving tissue healing as well as serum protein levels, vitamins and electrolytes. Therapy with tamoxifen and sodium thiosulfate effectively delayed the development of EPS.

[Duodenal duplication cyst filled with enteroliths: a case report]. / Cisto de duplição do duodeno com cálculos: Apresentação de caso.

Alimentary tract duplications are very rare, especially among adults, and only in 4-12% of the cases the duodenum is the site of origin. The main symptoms are usually epigastric pain, weight loss and vomiting. We report a case of a duodenal duplication cyst filled with enteroliths in a 23-year-old female patient presenting these symptons. The computed tomography showed a mesenteric cyst and the patient underwent a surgical procedure during which the diagnosis of duplication cyst with enteroliths was made and the cyst was excised with success. The diagnosis before surgery in these cases is extremely difficult especially if one considers how rare they are. The most helpful exam is the computed to- mography and the treatment is mainly surgical, although there are recent case reports showing the possibility of endoscopic resection (still being discussed). The presence of enteroliths can be explained by stasis and food alkalinity inside the cyst.

[Critical value of citrulline for complications of intestinal transplant graft]. / Valor crítico da citrulina para as complicações do enxerto no transplante de intestino.

OBJECTIVE: A biochemical marker for detection of acute cellular rejection following small intestine transplantation has been sought. Citrulline, a non- protein amino acid synthesized mainly by functioning enterocytes, has been proposed. Trial sensitivity has been reportedly high but with low specificity. Thus, the goal was to determine, in a sufficiently large analysis, the significant value of citrulline level in the post-transplant setting, which would correlate with complications such as rejection and infection. METHODS: Since March, 2004 2,135 dried blood spot (DBS) citrulline samples were obtained from 57 small intestine transplant recipients three months or more after post-transplant, i.e., once the expected period of recovery in the citrulline levels had occurred. RESULTS: Using a <13 vs. > 13 micromoles/L cut off point, sensitivity of DBS citrulline for the detection of moderate or severe ACR was extremely high (96.4%). Furthermore, specificity estimates (given the absence of ACR and these particular infections), while controlling for time-to-DBS sample were reasonably high (54%-74% in children and 83%-88% in adults), and the negative predictive value (NPV) was >99%. CONCLUSION: Citrulline is a non-invasive marker to evaluate problems of the intestinal graft after three months post-transplant. Due to the high NPV, a moderate or severe ACR can be ruled out, based exclusively on knowledge of a high value for DBS citrulline.

Association of nonalcoholic fatty liver disease and liver cancer.

AIM: To investigate the association between nonalcoholic fatty liver disease (NAFLD) and liver cancer, and NAFLD prevalence in different liver tumors. METHODS: This is a retrospective study of the clinical, laboratory and histological data of 120 patients diagnosed with primary or secondary hepatic neoplasms and treated at a tertiary center where they underwent hepatic resection and/or liver transplantation, with subsequent evaluation of the explant or liver biopsy. The following criteria were used to exclude patients from the study: a history of alcohol abuse, hepatitis B or C infection, no tumor detected in the liver tissue examined by histological analysis, and the presence of chronic autoimmune hepatitis, hemochromatosis, Wilson's disease, or hepatoblastoma. The occurrence of NAFLD and the association with its known risk factors were studied. The risk factors considered were diabetes mellitus, impaired glucose tolerance, impaired fasting glucose, body mass index, dyslipidemia, and arterial hypertension. Presence of reticulin fibers in the hepatic neoplasms was assessed by histological analysis using slide-mounted specimens stained with either hematoxylin and eosin or Masson's trichrome and silver impregnation. Analysis of tumor-free liver parenchyma was carried out to determine the association between NAFLD and its histological grade. RESULTS: No difference was found in the association of NAFLD with the general population (34.2% and 30.0% respectively, 95%CI: 25.8-43.4). Evaluation by cancer type showed that NAFLD was more prevalent in patients with liver metastasis of colorectal cancer than in patients with hepatocellular carcinoma and intrahepatic cholangiocarcinoma (OR = 3.99, 95%CI: 1.78-8.94, P < 0.001 vs OR = 0.60, 95%CI: 0.18-2.01, P = 0.406 and OR = 0.70, 95%CI: 0.18-2.80, P = 0.613, respectively). There was a higher prevalence of liver fibrosis in patients with hepatocellular carcinoma (OR = 3.50, 95%CI: 1.06-11.57, P = 0.032). Evaluation of the relationship between the presence of NAFLD, nonalcoholic steatohepatitis, and liver fibrosis, and their risk factors, showed no significant statistical association for any of the tumors studied. CONCLUSION: NAFLD is more common in patients with liver metastases caused by colorectal cancer.

An analysis of tacrolimus-related complications in the first 30 days after liver transplantation.

OBJECTIVES: Orthotopic liver transplantation has improved survival in patients with end-stage liver disease; however, therapeutic strategies that achieve ideal immunosuppression and avoid early complications are lacking. To correlate the dose and level of Tacrolimus with early complications, e.g., rejection, infection and renal impairment, after liver transplantation. From November 2011 to May 2013, 44 adult liver transplant recipients were studied in this retrospective comparative study. RESULTS: The most frequent indication for liver transplantation was hepatitis C cirrhosis (47.7%), with a higher prevalence observed in male patients (68.18%). The ages of the subjects ranged from 19-71 and the median age was 55.5 years. The mean length of the hospital stay was 16.1±9.32 days and the mean Model for End-stage Liver Disease score was 26.18±4.28. There were five cases of acute cellular rejection (11.37%) and 16 cases of infection (36.37%). The blood samples that were collected and analyzed over time showed a significant correlation between the Tacrolimus blood level and the deterioration of glomerular filtration rate and serum creatinine (p<0.05). Patients with infections had a higher serum level of Tacrolimus (p = 0.012). The dose and presence of rejection were significantly different (p = 0.048) and the mean glomerular filtration rate was impaired in patients who underwent rejection compared with patients who did not undergo rejection (p = 0.0084). CONCLUSION: Blood Tacrolimus levels greater than 10 ng/ml were correlated with impaired renal function. Doses greater than 0.15 mg/kg/day were associated with the prevention of acute cellular rejection but predisposed patients to infectious disease.

Small bowel transplantation.

BACKGROUND: Small bowel transplantation evolution, because of its complexity, was slower than other solid organs. Several advances have enabled its clinical application. AIM: To review intestinal transplantation evolution and its current status. METHOD: Search in MEDLINE and ScIELO literature. The terms used as descriptors were: intestinal failure, intestinal transplantation, small bowel transplantation, multivisceral transplantation. Were analyzed data on historical evolution, centers experience, indications, types of grafts, selection and organ procurement, postoperative management, complications and results. CONCLUSION: Despite a slower evolution, intestinal transplantation is currently the standard therapy for patients with intestinal failure and life-threatening parenteral nutrition complications. It involves some modalities: small bowel transplantation, liver-intestinal transplantation, multivisceral transplantation and modified multivisceral transplantation. Currently, survival rate is similar to other solid organs. Most of the patients become free of parenteral nutrition.

Analysis of transplant rejection in rabbits aponeurosis.

OBJECTIVE: To study the feasibility of heterologous aponeurosis to close the abdominal wall of rabbits emphasizing the rejection process. METHODS: This project was approved by the Animals Care Committee of the Faculdade de Ciências Médicas da Santa Casa de São Paulo, and it was carried out at the Experimental Surgery and Technical Unit. Four red female rabbits exchanged abdominal wall aponeurosis with other four white male animals. Two rabbits just had it removed and replaced to be the control group for the healing process. Animals were evaluated once a day, and after 7 days they were sacrificed. Immunohistochemical analysis with CD20 and CD79 was done. RESULTS: The animals did not have cellulitis, abscess, hematoma, wound dehiscence or herniation. The graft site showed intense hyperemia. The histological analysis showed an inflammatory process with maturing myofibroblasts and collagen ranging from incipient to moderate. The number of vessels was reduced and the inflammatory cells were most plasma cells and macrophages. There were no morphological signs of acute rejection with aggressive vascular endothelial damage. The adjacent muscle showed signs of degeneration with inflammatory centralization of nuclei and cytoplasmic condensation. The immunohistochemical analysis (CD20 and CD79) showed that the inflammatory process was not mediated by lymphocytes. Mann-Whitney nonparametric test showed that the hypothesis of equality (p>0.05) should not be discarded. CONCLUSION: There were no postoperative complications (fistulas, dehiscence etc.) and the histological analysis showed nonspecific inflammatory process. The immunohistochemical analysis showed that the inflammatory process was not due to a possible rejection.

Liver transplant outcome: a comparison between high and low MELD score recipients.

OBJECTIVE: To compare low and high MELD scores and investigate whether existing renal dysfunction has an effect on transplant outcome. METHODS: Data was prospectively collected among 237 liver transplants (216 patients) between March 2003 and March 2009. Patients with cirrhotic disease submitted to transplantation were divided into three groups: MELD > or = 30, MELD < 30, and hepatocellular carcinoma. Renal failure was defined as a +/- 25% decline in estimated glomerular filtration rate as observed 1 week after the transplant. Median MELD scores were 35, 21, and 13 for groups MELD > or = 30, MELD < 30, and hepatocellular carcinoma, respectively. RESULTS: Recipients with MELD > or = 30 had more days in Intensive Care Unit, longer hospital stay, and received more blood product transfusions. Moreover, their renal function improved after liver transplant. All other groups presented with impairment of renal function. Mortality was similar in all groups, but renal function was the most important variable associated with morbidity and length of hospital stay. CONCLUSION: High MELD score recipients had an improvement in the glomerular filtration rate after 1 week of liver transplantation.

Multivisceral transplantation in pigs: a model for research and training.

OBJECTIVE: To present a model for research and training in multivisceral transplantation in pigs. METHODS: Eight Large White pigs (four donors and four recipients) were operated. The multivisceral transplant with stomach, duodenum, pancreas, liver and intestine was performed similarly to transplantation in humans with a few differences, described below. Anastomoses were performed as follows: end-to-end from the supra-hepatic vena cava of the graft to the recipient juxta diaphragmatic vena cava; end-to-end from the infra-hepatic vena cava of the graft to the inferior (suprarenal) vena cava of the recipient; and end-to-side patch of the aorta of the graft to the infrarenal aorta of the recipient plus digestive reconstruction. RESULTS: The performance of the multivisceral transplantion was possible in all four animals. Reperfusions of the multivisceral graft led to a severe ischemia-reperfusion syndrome, despite flushing of the graft. The animals presented with hypotension and the need for high doses of vasoactive drugs, and all of them were sacrificed after discontinuing these drugs. CONCLUSION: Some alternatives to minimize the ischemia-reperfusion syndrome, such as the use of another vasoactive drug, use of a third pig merely for blood transfusion, presence of an anesthesia team in the operating room, and reduction of the graft, will be the next steps to enable experimental studies.

Diretrizes para avaliação e validação do potencial doador de órgãos em morte encefálica / Guidelines for the assessment and acceptance of potential brain-dead organ donors

RESUMO O transplante de órgãos é a única alternativa para muitos pacientes portadores de algumas doenças terminais. Ao mesmo tempo, é preocupante a crescente desproporção entre a alta demanda por transplantes de órgãos e o baixo índice de transplantes efetivados. Dentre as diferentes causas que alimentam essa desproporção, estão os equívocos na identificação do potencial doador de órgãos e as contraindicações mal atribuídas pela equipe assistente. Assim, o presente documento pretende fornecer subsídios à equipe multiprofissional da terapia intensiva para o reconhecimento, a avaliação e a validação do potencial doador de órgãos.

ABSTRACT Organ transplantation is the only alternative for many patients with terminal diseases. The increasing disproportion between the high demand for organ transplants and the low rate of transplants actually performed is worrisome. Some of the causes of this disproportion are errors in the identification of potential organ donors and in the determination of contraindications by the attending staff. Therefore, the aim of the present document is to provide guidelines for intensive care multi-professional staffs for the recognition, assessment and acceptance of potential organ donors.

Pancreas transplantation: an overview.

Pancreas transplantation is the only treatment able to reestablish normal glucose and glycated hemoglobin levels in insulin-dependent diabetic patients without the use of exogenous insulin. The evolution of pancreas transplantation in treatment of diabetes was determined by advances in the fields of surgical technique, organ preservation and immunosuppressants. The main complication leading to graft loss is technical failure followed by acute or chronic rejection. Technical failure means graft loss within the first three months following transplantation due to vascular thrombosis (50%), pancreatitis (20%), infection (18%), fistula (6.5%) and bleeding (2.4%). Immunological complications still affect 30% of patients, and rejection is the cause of graft loss in 10% of cases. Chronic rejection is the most common late complication. Cardiovascular diseases are the most common causes of late mortality in pancreas transplantation, so it remains the most effective treatment for type 1 diabetes patients. There is a significant improvement in quality of life and in patient's survival rates. The development of islet transplantation could eliminate or minimize surgical complications and immunosuppression.

[Intestinal lengthening using a gastric graft: experimental study in pigs]. / Alongamento de intestino com tubo gástrico: estudo piloto em porcos.

OBJECTIVE: Novel experimental technique of intestinal lengthening with a gastric graft in swines is proposed. METHODS: Four male large white swines, weighing 15 to 20 kg and aging 50 to 60 days were underwent an intestinal lengthening using a gastric graft (Figure 1). Swines were re-operated to check the aspect of the lengthening surgery. At this time intestinal fragments of suture lines, respecting a 5 cm margin, were removed and sent to histological analysis. RESULTS: There wasn't any graft ischemia or necrosis, residual stomach was already dilated by the time of relaparotomies, regaining 50% of its original size. Only an intense atrophy of the gastric graft mucosa with no signs of necrosis at histological study (Figure 2). CONCLUSION: Lengthening using a gastric graft is technically feasible, with viability of the graft. Studies with swines with SBS in a larger cohort will be necessary to analyze stomach graft function. In the future, this technique can be a bridge to intestinal transplantation.