Resection and transplantation: evaluation of surgical perspectives in HIV positive patients affected by end-stage liver disease.

PURPOSE: The aim of this study was to evaluate the opportunity of surgical treatment in terms of liver resection or liver transplantation in HIV positive patients affected by an end stage liver disease that referred to our liver unit. METHODS: Among 1350 outpatients who referred to our liver unit from January 2002 to September 2003, thirty-two (2,4%) were HIV positive. The routes of transmission of the viral infection, the related co-infections and the underlying liver disease were recorded. The therapeutic pathway was analysed. The kind and the duration of the surgical procedures were assessed. RESULTS: Fourteen (44%) of these thirty-two patients were not suitable for surgical treatment. Surgery was planned in 9 of 32 HIV positive patients (28%). Four patients (12%) were submitted to liver resection and OLT was performed in five patients (15%). Hepatocellular Carcinoma was present in 4 (44%) of the HIV positive patients considered for surgery. CONCLUSIONS: In conclusion in our centre the 28% of HIV positive out patients had the opportunity to receive a surgical treatment. The candidate to this surgery is mostly young, HCV and/or HBV coinfected and affected by HCC in 44% of cases.

[Acute liver toxicity of antiretroviral therapy (HAART) after liver transplantation in a patient with HIV-HCV coinfection and associated hepatocarcinoma (HCC)]. / Tossicità epatica acuta da terapia antiretrovirale (HAART) dopo trapianto di fegato in un paziente con coinfezione da HIV-HCV ed associato epatocarcinoma (HCC).

OLT in HIV infected patients still remains a challenging option requiring a careful monitoring of patients for HCV reinfection, drug interactions and antiretroviral toxicity. Severe adverse events due to HAART have been already reported for post exposure prophylaxis in HIV infected patients. Here we report a case of liver graft toxicity related to HAART in a HIV-HCV co-infected patient (46 yrs-male) with associated a small HCC transplanted with a marginal liver graft. The patient had pre-OLT plasma HIV 1-RNA levels undetectable and CD4+ T-cell count of > 200 cells/microL for 6 months. At day 2 a severe graft dysfunction was observed (AST 1570 U/L, ALT 2180 U/L, BIL tot 8.3 mg/dL, BIL Dir 6.6 mg/dL and PT 35%--INR 2.5). Doppler scan showed hepatic artery always patient. Later the postoperative in-hospital course was complicated by tense ascites and severe cholestasis. Serum bilirubin reached 42 mg/dL in day 12. Hypertransaminasemia ended at day 15 while cholestasis ended after 46 days. Tacrolimus was reintroduced at day 7. A liver biopsy 10 after OLT showed severe intrahepatic cholestasis, centrolobular necrosis and macrovesicular steatosis (30%). The patient was discharged 48 days after OLT with good liver function. After seven months HIV-RNA is still undetectable and HAART has not been restarted. We believe that the early complications we observed may be attributed to a sudden increase in plasma concentration of antiretroviral drugs secondary to drug redistribution from peripheral tissues and hepatic clearance deficiency after OLT. Although a pre-OLT withdrawal of HAART seems unjustified a delayed re-introduction of HAART or the use of less hepatotoxic drugs may be advisable.

Neuroadenolysis of the pituitary.

The authors describe the neuroadenolysis of the pituitary (NALP), an original antalgic technique consisting in the injection of small amounts of alcohol into the sella turcica. Used for diffuse pain from advanced cancer, NALP determines, in addition to the antalgic effect, a temporary regression in the evolution of the neoplastic disease in approximately 30% of the cases of hormonedependent tumors. The consequences and complications are generally not very serious, allowing the use of this technique in poor-risk patients. The authors also discuss the results, the mechanism of the antalgic effect and the studies carried out with a view to defining such mechanism. To this end, the authors stress the importance of the electrophysiological approach and described the first experiments involving the technique of cortical evoked potentials in patients who have undergone NALP. (Acta anaesth. belg., 1981, 32, 87-99).

[Randomized study on the use of propofol for anesthesia in intracranial tumors. Comparison with balanced anesthesia]. / Studio randomizzato sull'uso del propofol nell'anestesia dei tumori intracranici. Confronto con anestesia bilanciata.

There is currently no anesthesiological technique which enables volume, cerebral blood flow and spinal fluid pressure to be kept constant. The aim of the present study was to compare two techniques of anesthesia in patients with cerebral tumours: one of a balanced type (AB) and the other of a continuous ev type (AEC) using propofol in order to assess which guaranteed the greatest cerebral protection. The results of the study have shown that the use of propofol may represent a useful alternative in intracranial tumour surgery since changes in systolic pressure and heart rate observed during AEC anesthesia were statistically lower in comparison to AB anesthesia. No statistically significant differences were observed in relation to changes in diastolic pressure, PVC, ApCO2 and the incidence of bleeding or cerebral edema. The quality of awakening was better in patients in the AEC group in terms of renewed breathing and spontaneous motility, verbal response and space-time orientation.